ISSN 1830-7957 2010
ISSUE EUROPE IN USE SELECTED PROBLEM AMPHETAMINE AND METHAMPHETAMINE METHAMPHETAMINE AND AMPHETAMINE PROBLEM
PROBLEM AMPHETAMINE AND METHAMPHETAMINE SELECTED
USE IN EUROPE ISSUE
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Cais do Sodré, 1249-289 Lisbon, Portugal Tel. +351 211210200 • Fax +351 218131711 [email protected] • www.emcdda.europa.eu Contents
Introductory note and acknowledgements 5
Introduction 7
Part 1: Overview of amphetamines use in Europe 9
Historical background 9
Legislation 9
Supply: production and trafficking 10
Use of amphetamines in the general population 14
Use of amphetamines in recreational settings 15
Health consequences of amphetamines use 16
Part 2: Problem amphetamines use in Europe 21
Western and southern Europe 21
Northern Europe 24
Eastern and central Europe 26
Czech Republic and Slovakia 28
Conclusions 32
References 33
3
Introductory note and acknowledgements
In-depth reviews of topical interest are published as Selected issues each year. These reports are based on information provided to the EMCDDA by the EU Member States and candidate countries and Norway (participating in the work of the EMCDDA since 2001) as part of the national reporting process.
The most recent Selected issues are: • Trends in injecting drug use in Europe; • Drug offences: sentencing and other outcomes; • Polydrug use: patterns and responses.
All Selected issues (in English) and summaries (in up to 23 languages) are available on the EMCDDA website: http://www.emcdda.europa.eu/publications/selected-issues
The EMCDDA would like to thank the following for their help in producing this Selected issue: • the heads of Reitox national focal points and their staff; • the services within each Member State that collected the raw data; • the members of the Management Board and the Scientific Committee of the EMCDDA; • the Publications Office of the European Union.
Reitox national focal points
Reitox is the European information network on drugs and drug addiction. The network is comprised of national focal points in the EU Member States, Norway, the candidate countries and at the European Commission. Under the responsibility of their governments, the focal points are the national authorities providing drug information to the EMCDDA.
The contact details of the national focal points may be found at: http://www.emcdda.europa.eu/index.cfm?nnodeid=403
5
Problem amphetamine and methamphetamine use in Europe
Introduction amphetamines, cocaine, ecstasy, piperazines or new stimulant drugs such as mephedrone. Finally, Europe is an Amphetamine and methamphetamine are two closely important producer of amphetamines with several countries related synthetic substances that act as stimulants of the reporting illicit production facilities on their territory. central nervous system. They can be ingested, snorted or injected, and methamphetamine, particularly in its crystalline The provision of care for those with amphetamines problems form, can be smoked. The two substances can be so similar is another area in which differences exist between countries. in their effects and appearance that often the user cannot In general, treatment services are more attuned to the needs tell them apart. Their effects include elevated mood; a sense of amphetamines users in the countries where problematic of well-being; increased energy, wakefulness, concentration, use of these substances is longer established, while alertness, and motor and speech activities; improved elsewhere services are targeted to the needs of the largest performance in physical and mental tasks; and reduced group of problem drug users (2), mostly opioid users. fatigue. Among other effects viewed by users as positive and rewarding are decreased social or sexual inhibitions, Organised in two parts, this Selected issue aims to provide and the desire to lengthen social interactions or to socialise a comprehensive overview of the history, health effects, with others using the drug. This broad range of effects might supply and use of amphetamines in Europe, as well as explain why the use of amphetamines has been reported describing their problematic use and the responses to them among many different population groups including soldiers, in the European countries that are most heavily affected. The workers (e.g. truck or taxi drivers, hospital staff), students, first part begins with a short history of the use of these drugs sex workers, clubbers or problem heroin users. and a presentation of the laws that are used to control them. This is followed by an analysis of drug supply information, Of the main illicit drugs, the patterns and geography of mainly from police and customs services. The next section amphetamines (1) use in Europe are among the most difficult gives an overview of the prevalence of amphetamines use in to describe. There are several reasons for this. First, the the Europe population. The last section of Part I covers the prevalence of amphetamines use varies greatly between mental and physical health effects of amphetamines use, countries. The diversity of user groups is possibly one of the including a review of the information on infectious diseases largest of all illicit substances found in Europe. In addition, a and deaths related to these drugs. In Part 2, countries are small number of countries have problem amphetamines use grouped in four geographical regions and sub-regions at the heart of their drug problem and, when this is the case, according to their amphetamines problems, with particular it has very specific socio-historical and epidemiological attention given to those with significant levels of problem characteristics. The stimulant market in Europe also appears amphetamines use. Treatment responses to amphetamines to be changing frequently, particularly in nightlife settings, problems are also described for the different countries or with shifts in popularity between substances such as groups of countries.
(1) Here, amphetamine and methamphetamine are referred to collectively as amphetamines. (2) Problem drug use is defined as ‘injecting drug use or long-duration/regular use of opioids, cocaine and/or amphetamines’; for more information see the EMCDDA website.
7 EMCDDA 2010 Selected issue
Data and focus of this report Countries providing additional data This Selected issue is based on data routinely collected by the Countries not providing additional EMCDDA, reports in the scientific literature as well as a special data, but with evidence of problem data collection in 14 countries in which amphetamines use is amphetamines use particularly relevant in the national drug situation (1). Therefore, some of the information presented in this report covers the 27 EU Member States, Norway and the candidate countries Croatia and Turkey, while other sections focus on all or some of the 14 countries that reported data for this Selected issue. Much of the information on which this Selected issue is based is published in the national languages of the reporting countries, and has been reported to the EMCDDA as part of the 2009 National reports provided by each country. In general, these sources are not explicitly referred to in the text of this publication, but the reader can refer to the Reitox National reports, available online on the EMCDDA website, for a full list of sources.
(1) Belgium, Czech Republic, Estonia, Latvia, Luxembourg, Hungary, Netherlands, Poland, Slovakia, Finland, Sweden, United Kingdom, Croatia, Norway.
8 Part 1: Overview of amphetamines use in Europe
Historical background low. Toward the close of that decade, countries in the north of Europe experienced another wave of amphetamines use, Amphetamine was first synthesised in Germany in 1887, with problem amphetamines users outnumbering problem methamphetamine powder in 1893 and crystal opioid users. Indications of amphetamines use appeared in methamphetamine in 1918/19 in Japan. Widespread the Baltic States and Poland only in the 1990s, since when it medicinal use of the drugs in Europe appears to date from has increased. In much of southern Europe, amphetamines the 1930s, with the introduction of benzedrine have never been among the most prevalent drugs. Current (amphetamine) and pervitin (methamphetamine) as over-the- patterns of supply and demand in Europe reflect the history counter medicines. The stimulatory effects of these of amphetamines in the region. substances on the central nervous system were soon recognised, and amphetamine and methamphetamine tablets were widely distributed to troops during the Second Legislation World War. Synthetic psychoactive substances are controlled In the 1940s and 1950s, as accounts about side-effects and internationally by the United Nations Convention on addiction surfaced, countries attempted to restrict the Psychotropic Substances of 1971, which lists them in four availability of amphetamines by making them prescription Schedules requiring different levels of control. Amphetamine drugs. In the 1960s, recreational amphetamines use reached and methamphetamine are listed in Schedule II, which high levels among some sub-populations in parts of Europe. contains ‘substances whose liability to abuse constitutes a Control measures culminated in the 1970s with the adoption substantial risk to public health and which have little to at UN level of the International Convention on Psychotropic moderate therapeutic usefulness’ (UN, 1976). In the Substances (3). European Union, these substances are classified as illicit drugs in all Member States. Together with the control measures on amphetamines, the arrival of heroin on the drugs market saw the use of About half of the European Union’s Member States have amphetamines dwindle in most western European countries, laws that set out the same penalty for all drugs, whereas as problem drug users switched over to heroin. In others vary the level of penalty available for the substance Scandinavian countries, however, amphetamines retained according to the level of harm it may cause (regardless of their popularity. While amphetamines were still available as any therapeutic value). A distinction between drugs may prescription drugs in Czechoslovakia in the 1970s, also be made depending on the offence; penalties may be manufacturing in kitchen labs and injecting of equal for personal use offences but may differ for supply methamphetamine emerged. In what is now the Czech offences, or vice versa. No country that varies penalties Republic, small closed groups of users organised around depending on the type of drug involved has set penalties for methamphetamine producers, and by the late 1980s most offences involving amphetamine and methamphetamine at people who were dependent on drugs other than alcohol the lowest level. Of these countries, all except the United were pervitin users. Kingdom legally class the two drugs equally. Under United Kingdom law, amphetamine is in class B while, following In the 1990s, the emergence of the electronic music scene reports of increased use and production, methamphetamine led to a rise in amphetamines use in recreational settings, was moved in 2007 from class B to class A, the ‘most though the prevalence of problem use of the drug remained harmful’ category.
(3) The International Convention on Psychotropic Substances is available online.
9 EMCDDA 2010 Selected issue
(MHRA, 2008). The Czech National Institute for Drug Amphetamine and methamphetamine Control also changed from 1 May 2009 the marketing authorisation, to restrict over-the-counter medicines Amphetamine (CAS-300-62-9) and methamphetamine containing pseudoephedrine (those with up to 30 mg per (CAS-537-46-2) are members of the phenethylamine family, tablet) to a maximum monthly dose of 1 800 mg of which includes a range of substances that may be pseudoephedrine (i.e. 60 tablets, 30 mg each) per person. stimulants, entactogens or hallucinogens. Thus, Mail order sales were banned, and supply would be amphetamine is N,α-methylphenethylamine and monitored via the central database of electronic methamphetamine is N,α-dimethylphenethylamine, or by prescriptions. In November 2009, the maximum was their International Union of Pure and Applied Chemistry reduced to 900 mg (30 tablets) of pseudoephedrine per (IUPAC) systematic names N,α-methylbenzeneethanamine and N,α-dimethylbenzeneethanamine, respectively. single purchase in pharmacies. The restriction was changed due to a ban on the use of a central database for electronic
Amphetamine Methamphetamine prescription with regard to issues of personal data Molecular structure Molecular structure protection. Importation of medicines containing pseudoephedrine from neighbouring countries (Germany NH CH 2 NH 3 and, to a greater extent, Poland) has reportedly increased greatly since June 2009. This increase is thought to be in CH3 CH3 response to the reduced availability of these medicines through Czech pharmacies. Molecular formula: C9H13N Molecular formula: C10H15N Molecular weight: 135.2 Molecular weight: 149.2 Supply: production and trafficking More information is available on the EMCDDA online drug profiles on amphetamine and methamphetamine. Synthetic drugs such as amphetamines tend to be produced in or near their consumer markets. Therefore, compared to plant-based drugs such as cannabis, heroin and cocaine, In recent years, the Czech Republic and the United Kingdom they are less frequently the subject of transcontinental have introduced restrictions on the sale of cold remedies trafficking activities. This, however, may not be true for their containing pseudoephedrine, as they are purchased to make precursor chemicals, especially ephedrine and illicit amphetamines. Following reports that pseudoephedrine, used for methamphetamine production, methamphetamine was being illegally manufactured using and 1-phenyl-2-propanone (P2P, or benzyl methyl ketone, pseudoephedrine and ephedrine contained in cold and flu BMK), which is mostly used to produce amphetamine and remedies, the United Kingdom’s Medicines and Healthcare may also be used to manufacture methamphetamine. Data Products Regulatory Agency (MHRA) limited from 1 April presented in this section, mainly from police sources, can be 2008 over-the-counter sales of products containing these used to build up a picture of the production and trafficking precursors, restricting these to packs containing not more activities related to amphetamines and their precursors and than 720 mg pseudoephedrine and 180 mg ephedrine. to describe the products available on the illicit drugs Larger packs would be available on prescription only markets, their price and purity.
10 Problem amphetamine and methamphetamine use in Europe
known as ‘Captagon’, which are reported to contain Seizures and market data: sources and amphetamine trafficked from south-east Europe to the interpretation Arabian Peninsula (CND, 2009).
Systematic and routine information to describe illicit drug Production of amphetamine in Europe is concentrated in the markets and trafficking is limited. Drug seizures are often Netherlands, Poland and Belgium, and some is produced in considered as an indirect indicator of the supply, trafficking Estonia, Lithuania and Germany. In 2008, 39 sites involved routes and availability of drugs. They are a more direct in the production, tabletting or storage of amphetamine indicator of drug law enforcement activities (e.g. priorities, were discovered in the European Union and reported to resources, strategies), while also reflecting both reporting Europol: 15 in the Netherlands, 11 in Poland, nine in practices and the vulnerability of traffickers. Data on purity Germany, three in Belgium and one in Lithuania (see and retail prices of illicit drugs may also be analysed in Figure 1). Of the 39 sites, 28 handled only amphetamine, order to understand retail drug markets. Retail prices of drugs reported to the EMCDDA reflect the price to the user. while the remaining 11 handled at least one additional Trends in price are adjusted for inflation at national level. synthetic drug, often MDMA. Reports on purity, from most countries, are based on a sample of all drugs seized, and it is generally not possible Law enforcement agencies in Europe reported more than to relate the reported data to a specific level of the drug 39 000 seizures of amphetamine powder amounting to 8.1 market. For purity and retail prices, analyses are based on tonnes of the drug in 2007 (4). This represents the largest the reported mean or mode or, in their absence, the annual amount of the drug seized, rising from 3.8 tonnes in median. The availability of price and purity data may be 2001. The Netherlands reported an estimated 2.8 tonnes of limited in some countries and there may be questions of amphetamine seized, representing 34 % of the European reliability and comparability. total, followed by the United Kingdom with 1.8 tonnes (22 %), Germany with 0.8 tonnes (10 %), Belgium with 0.5 The EMCDDA collects national data on drug seizures, tonnes (6 %), and Poland and Norway with 0.4 tonnes purity and retail prices in Europe. Other data on drug supply comes from UNODC’s information systems and each (5 %). analyses, complemented by additional information from Europol. Information on drug precursors is obtained from The purity of amphetamine samples intercepted in Europe in the European Commission, which collects data on seizures 2008 varied widely. The mean purity of samples ranged of these substances in the European Union, and the INCB, from less than 10 % in Denmark, Austria, Portugal, Slovenia, which is involved in international initiatives to prevent the the United Kingdom, Croatia and Turkey, to greater than diversion of precursor chemicals used in the manufacture of 25 % in Latvia, the Netherlands, Poland and Norway. In illicit drugs. most of the 17 countries with sufficient data for analysis of trends over the past five years, the purity of amphetamine The data and estimates presented in this report are the best has been decreasing or remained stable (5). approximations available, but must be interpreted with caution, as many parts of the world still lack sophisticated In 2008, the mean retail price of a gram of amphetamine information systems related to drug supply. ranged from EUR 6 to EUR 36 in the 17 reporting countries, and it was EUR 9–20 in over half of them. In all 13 countries reporting data over the five-year period 2003–08, amphetamine retail prices decreased or Amphetamine remained stable (6).
Europe accounted for more than 80 % of all amphetamine Global seizures of the precursor chemical P2P increased facilities discovered in 2008, while global seizures of the sharply to 5 260 litres in 2008 from 830 litres in 2007 and drug in 2008 totalled 23 tonnes, 98 % of which was 2 600 litres in 2006. Seizures of P2P in the European Union confiscated in two regions, western Asia (14 tonnes) and increased to 629 litres from 582 litres in 2007. Most of the Europe (8 tonnes) (UNODC, 2010). Most of the P2P intercepted in 2008 was confiscated in a large seizure amphetamine seized in western Asia is in the form of tablets of 564 litres in Lithuania, while Poland and Estonia reported
(4) Most recent year with data available from the two countries reporting the largest quantities seized. The data on European amphetamine seizures can be found in Tables SZR-11 and SZR-12 in the 2010 statistical bulletin. (5) The data on European amphetamine purity can be found in Table PPP-8 in the 2010 statistical bulletin. (6) The data on European drug prices mentioned in this section can be found in Table PPP-4 in the 2010 statistical bulletin.
11 EMCDDA 2010 Selected issue
Figure 1: Dismantled illicit amphetamines facilities reported to Europol in 2008
Substance Type of facility x Amphetamine Production Methamphetamine Storage 1 1 1 1 Tabletting 1 1 1 6 2 3
1
1 1 1 1 1 2 1 1 1 1 1 1 1 1 1 3 7 1 1 1 2 458 2 1 3 2 5 1 2
NB: This map displays the approximate location of illicit amphetamine and methamphetamine facilities uncovered in EU Member States in 2008, as reported to Europol. Where possible, the distribution of reported facilities is presented on a sub-national basis. In the Czech Republic, due to the large number of sites dismantled and the lack of information on the location for many of them, a national value is given. One site was also located in the Portuguese Azores Islands. Drug type is denoted by the symbol colour, with the number of facilities reported in the country or region indicated. Facilities handling both amphetamine and methamphetamine are indicated by two-colour symbols. Source: Europol.
seizures totalling 39 litres and 22 litres, respectively (INCB, manufacture their own P2P from so-called ‘pre-precursors’ 2010). Russia, which apparently replaced China as the main such as phenylacetic acid and benzyl cyanide. source of P2P used to manufacture amphetamines in the European Union in recent years (EMCDDA–Europol, 2009), Methamphetamine and where amphetamine is also manufactured illegally (UNODC, 2010), reported seizing a total of 2 130 litres of World methamphetamine production is concentrated in east the chemical in 2008, or about 10 times more than in 2007 and south-east Asia and North America, especially Mexico, (191 litres) (INCB, 2010). but the drug is also increasingly manufactured in Oceania, South and Central America and southern Africa. In 2008, A relatively new trend in P2P trafficking is the ‘masking’ of 18 tonnes of methamphetamine was seized worldwide, the chemical, which is normally found in liquid form, into a continuing a stable trend since 2004. Most of the drug was powder known as P2P bisulphite, prior to importation into seized in east and south-east Asia, notably China, followed the European Union. It should also be noted that some by North America, particularly the United States (UNODC, European producers of amphetamine, for instance in Poland, 2010).
12 Problem amphetamine and methamphetamine use in Europe
Reported seizures of methamphetamine in Europe are small in number and quantity compared to those of amphetamine. Methamphetamine In 2008, law enforcement agencies in 17 countries reported about 4 650 seizures totalling 302 kg of methamphetamine. Methamphetamine can come in various shapes and forms. Nordic and Baltic countries accounted for more than 95 % Powder methamphetamine found on the illicit drugs market is similar to powder amphetamine in many ways, including of all methamphetamine seized in Europe, with Norway purity and appearance, and the two can be reporting seizures of 103 kg (34 % of the European total) indistinguishable for both users and dealers. Most users of and Sweden 75 kg (25 %), followed by Estonia (38 kg, powder amphetamines snort or inject the drug. Crystal 12 %), Latvia (32 kg, 11 %), Lithuania (26 kg, 9 %) and methamphetamine, in contrast, is often of very high purity. Finland (17 kg, 6 %). Despite the large number of It comes in the form of white or translucent crystals, and methamphetamine facilities discovered in the Czech users mostly smoke, snort, or inject it. Methamphetamine in Republic (see below), reported seizures amounted to only tablet form is often mixed with other drugs, and sold as 4 kg of the drug (1 % of the European total), equal to the ‘ecstasy’. Methamphetamine base is an oily paste, which amount reported by Germany. The countries reporting the may be purified into methamphetamine hydrochloride salt largest numbers of methamphetamine seizures in 2008 were or crystals. There is growing evidence that smoking crystal Norway (1 380) and Sweden (846), followed by Slovakia methamphetamine has more harmful psychological effects (774), Latvia (494), the Czech Republic (405), Germany and a higher addictive potential than other forms of methamphetamine use — probably due to its considerably (356), Lithuania (162) and Finland (120). higher purity and route of administration. While use of crystal methamphetamine is increasingly prevalent in many Both the total amount of methamphetamine seized in Europe parts of the world, in Europe, methamphetamine is almost and the number of seizures of the drug have been exclusively found in powder form. increasing since 2001, with the greatest amount seized recorded in 2007 (336 kg) and the highest number of seizures in 2008. central Europe, extraction of ephedrine and The mean retail price of methamphetamine, reported by six pseudoephedrine from over-the-counter medical countries, ranged between EUR 12 and EUR 126 a gram in preparations appears to be the main source of these 2008. The mean purity of the drug ranged between 22 % precursors for illicit methamphetamine production. and 80 % in the 14 countries reporting it, with only three countries reporting mean purity levels above 60 %: Belgium Large-scale methamphetamine trafficking operations, (80 %), the Czech Republic and Slovakia (both 64 %). though reported to some extent in central Europe, especially in the Czech Republic, are more characteristic By global standards, illicit supply of methamphetamine in of a second hub of methamphetamine supply, centred Europe is small-scale, and centred around two regions: round the Baltic Sea. This, probably, more recent supply central Europe and the Baltic Sea (EMCDDA–Europol, source links the Baltic countries, especially Lithuania and 2009). Until recently, methamphetamine production was Estonia, and possibly Poland, to Scandinavian countries, largely confined to the Czech Republic, where 458 mostly especially Sweden and Norway (but also Russia and small-scale production sites were dismantled in 2008 and Belarus), and is reported to involve players trafficking reported to Europol. This is the highest number ever larger quantities of methamphetamine (EMCDDA–Europol, reported by the Czech Republic of methamphetamine 2009). Although no methamphetamine production ‘kitchen laboratories’, which typically produce a few facilities have been seized in recent years, Lithuania and grams of the drug at a time. Small quantities of Estonia both report that methamphetamine is methamphetamine produced in the Czech Republic are manufactured on their territories, most likely from P2P probably exported to neighbouring countries, especially sourced from outside the European Union. Lithuanian Slovakia and Germany (EMCDDA–Europol, 2009). nationals have been arrested at border crossings in However, seizures of methamphetamine production Sweden and Norway smuggling methamphetamine facilities were also reported to Europol in countries shipments weighing about 10 kg, but sometimes as much neighbouring the Czech Republic including Slovakia, as 50 kg at a time (EMCDDA–Europol, 2009). Lithuanian Germany and Poland (see Figure 1), while Austria nationals were also involved in many of the seizures of reported seizing three ‘kitchen labs’ in 2008. It seems that P2P that took place in Europe in 2008 and, according to methamphetamine supply in central Europe is largely Lithuanian authorities, were arrested in connection with organised around small-scale production facilities run by methamphetamine seizures in Ireland and the United users for their own needs and for some limited sales. In Kingdom totalling 6 kg and 8 kg respectively.
13 EMCDDA 2010 Selected issue
Belgium, Portugal and the United Kingdom also reported Figure 2: Last year prevalence of amphetamines use among young methamphetamine production facilities in 2008, while the adults (15–34 years) in Europe Netherlands reported the seizure of three storage facilities.
The INCB reports considerable decreases in world seizures in 2008 of two key precursors of methamphetamine: 13 tonnes of ephedrine in bulk form, down from 22 tonnes in 2007, and 5 tonnes of pseudoephedrine in bulk form, down from 25 tonnes in 2007. EU Member States accounted for Prevalence (%) >2.5 0.25 tonnes of ephedrine (mainly the Netherlands, Germany 2.1–2.5 and Bulgaria), and over 0.5 tonnes of pseudoephedrine 1.6–2.0 (almost all in France), but the amounts were small compared 1.1–1.5 to the previous year. The INCB warns that global seizures of 0.6–1.0 tablets containing ephedrine and pseudoephedrine, which >0.5 No data are increasingly used to produce methamphetamine in Europe and elsewhere, are probably underreported (INCB, 2010).
Use of amphetamines in the general population
The overall prevalence of amphetamines use in Europe can be estimated from general population surveys. Surveys of schoolchildren, generally in their mid-teens, provide an NB: Data from population surveys, with year of survey are: Czech Republic insight into the use of these substances by young people at a (2008) 3.2 %, Denmark (2008) 3.1 %, Estonia (2008) 2.5 %, United Kingdom (England and Wales) (2008/09) 2.3 %, Bulgaria (2008) 2.1 %, vulnerable phase in their development. As levels of Norway (2004) 2.0 %, Latvia (2007) 1.9 %, Finland (2006) 1.7 %, Spain amphetamines use are low in most countries, targeted (2007/08) 1.7 %, Germany (2006) 1.6 %, Sweden (2008) 1.5 %, Poland studies of settings or populations within which higher (2006) 1.3 %, Hungary (2007) 1.2 %, Lithuania (2008) 1.1 %, Austria prevalence of amphetamines use can be expected are a (2008) 0.9 %, Ireland (2006/07) 0.8 %, Slovakia (2006) 0.7 %, Netherlands (2005) 0.7 %, Italy (2008) 0.6 %, Portugal (2007) 0.4 %, Cyprus (2006) complementary source of information. 0.3 %, France (2005) 0.2 %, Greece (2004) 0.1 %, Romania (2007) 0.1 %. For more information, see Figure GPS-5 in the 2010 statistical bulletin. It is estimated that, overall, around 12 million European Sources: National focal points. adults aged 15–64 have tried amphetamines at least once in their lives (7) and 1.5 million (1.2 %) young Europeans (aged 15–34 years) have used amphetamines during the group, the United Kingdom has witnessed a long-term last year. At national level, last year use of amphetamines decline from a high of 6.2 % in 1998 to 2.3 % in 2008/09. among young adults ranges from 0.1 % to 3.2 %. Denmark, over a similar timescale, reports an increase from Prevalence levels of more than 2 % have been reported by 0.5 % in 1994 to 3.1 % in both 2000 and 2008 (9). the Czech Republic (3.2 %), Denmark (3.1 %), Estonia Prevalence estimates for amphetamines are available since (2.5 %), the United Kingdom (England and Wales) (2.3 %) 2002 for the Czech Republic and 2005 for Bulgaria, the and Bulgaria (2.1 %) (Figure 2). only countries to report a change of more than one percentage point during the last five years (Bulgaria, from Population surveys suggest that the prevalence of 0.9 % in 2005 to 2.1 % in 2008; and the Czech Republic, amphetamines use across Europe is generally stable, with from 1.5 % in 2004 to 3.2 % in 2008). most countries reporting broadly constant levels since the 1990s (8). Among countries reporting the highest last year Lifetime prevalence of amphetamines use among 15- to prevalence levels of amphetamines use in the 15 to 34 age 16-year-old school students is low across Europe. In 2007 or
(7) National prevalence data on amphetamines use presented here are based on general population surveys, which rarely include questions specifically about methamphetamine. Methamphetamine is included in the Czech questionnaire, but is not reported separately from amphetamine. In the United Kingdom, methamphetamine use was included in the questionnaire for the first time in the 2008/09 British Crime Survey. (8) See Figure GPS-8 in the 2010 statistical bulletin. (9) In Denmark, the 1994 information refers to ‘problem drugs’, which was considered mainly amphetamines.
14 Problem amphetamine and methamphetamine use in Europe
2008, it ranged from 1 % to 5 % in 23 EU Member States, Norway and Croatia, with higher levels reported only in Prevention of amphetamines use Bulgaria and Latvia (6 %) (10). Stable trends between 2003 and 2007/08 can be observed in the lifetime use of Most universal prevention programmes focus on health amphetamines among this population in the majority of the threats related to tobacco, alcohol and cannabis, and they rarely address the use of stimulants such as amphetamines. countries. An increase by at least two percentage points Selective prevention interventions addressing was observed in eight countries, and a decrease of at least amphetamines or stimulants use, however, are available in that amount only in Estonia. recreational settings. Most of these interventions provide information in brochures or print materials, or on the Use of amphetamines in recreational settings Internet, and have not yet been shown to be effective. The few evidence-based interventions that are available include direct and intensive personal counselling, mainly to Europe’s recreational nightlife economy has grown rapidly individuals who may be vulnerable based on behavioural over the past decades, particularly in electronic dance music factors. While these individuals may not approach regular settings. Young people in these settings report prevalence drug treatment services, they may benefit from motivational levels of stimulant drug use that are generally much higher interventions that address their consumption patterns. Other than among the general population. However, the types of interventions aim not at drug use itself but at its proportion of problem drug users may be relatively small, consequences, such as accidents, intoxications and acute and prevalence estimates vary considerably between health problems. These structural interventions, which are different settings and groups. available in some western European countries (Belgium, Denmark, Germany, Spain, Luxembourg, Netherlands, Studies from selected nightlife settings in nine countries in Austria, United Kingdom), target nightlife settings, and 2008 reported lifetime prevalence estimates for provide transport, chill-out zones, alcohol tests and crisis amphetamines use ranging from 5 % to 69 %. Some interventions. countries have suggested that amphetamines use in dance music settings has decreased during the last ten years, with the drug losing ground to ecstasy and cocaine powder use. An online survey of readers of the dance music magazine club-goers peaked at 13 % in 1998, and have since then Mixmag (11) in the United Kingdom in 2009–2010 showed decreased to a level lower than that in 1995 (6 % in 2008). that although many of the 2 295 respondents reported Among those reporting use of amphetamine in the last year, having used amphetamine (72 % ever, 30 % in the past year most use the drug seldom or occasionally (91 %), and often and 15 % in the past month), other substances are more together with alcohol (78 %). In contrast to some decades popular. Cocaine powder, for example, was used by more ago, in Amsterdam, amphetamine is nowadays almost respondents to the survey (87 % reported ever use, 83 % never used in public recreational settings such as bars or past-year use and 47 % past-month use). The survey also clubs. The drug is reported to be more commonly used found that while methamphetamine is also present in the UK during after-parties, for example when cocaine is not club scene, its prevalence is relatively low, with 6 % available, and people usually use less of it compared to reporting lifetime use, 1 % use in the last year and 0.3 % cocaine or ecstasy. Findings from qualitative studies suggest use in the last month. Viewed in the light of an earlier study that amphetamine use has been stable for years in some (McCambridge et al., 2005), there appears to have been no specific music scenes (underground, rock, punk, techno, change in the prevalence of methamphetamine use in this hard style) and in rural areas. Its low price makes it setting. Among men who have sex with men, though, the attractive for users who cannot afford more expensive prevalence of methamphetamine use is much higher — a drugs, such as cocaine. Although its popularity is growing study found that about one in five used it in the past year, among young people living in the country or in smaller and this prevalence remained stable between 2003 and cities, amphetamine has a negative image as a drug of 2005 (Bolding et al., 2006). ‘losers’ who cannot afford good quality drugs. The popularity of methamphetamine seems to be even lower Antenna studies among young people in Amsterdam show than that of amphetamine, though it might be growing that last month prevalence of amphetamine use among among specific populations, such as men who have sex
(10) A higher level of lifetime prevalence (8 %) was estimated for Austria, though qualitative follow-up work suggests that some students may have misunderstood the question, leading to an overestimation. The real prevalence is believed to be less than 8 %. (11) Personal communication, Adam Winstock, King’s College London.
15 EMCDDA 2010 Selected issue
with men and people who experiment with a wide variety Polydrug use, particularly with drugs that potentiate the of substances. In a survey carried out in 2008, 2.8 % of cardiovascular effects of amphetamines, such as alcohol, club-goers reported ever use of methamphetamine and opioids and cocaine, increases the toxicity of 0.5 % reported last month use of the drug. An internet amphetamines. survey targeting students of higher vocational schools and universities found 0.43 % lifetime prevalence. Short-term negative effects of amphetamines
In Czech nightlife settings, the prevalence of pervitin Amphetamines use, particularly at higher doses, may bring (methamphetamine) use is reported to have increased about restlessness, tremor, anxiety, dizziness, tension, between 2000 and 2007. In 2007, almost half of dance irritability, insomnia, confusion, aggression, and, in some partygoers reported having used methamphetamine at least individuals, psychotic symptoms and panic states. As once in their lives, 28 % in the last 12 months and 16 % in intensive amphetamines use often occurs in binges, a ‘crash’ the last 30 days. However, in contrast to problem or coming down is a common after-effect among users. A methamphetamine users, partygoers in the Czech Republic crash may last from several hours to several days, with use the drug mostly by snorting or orally, and very few inject symptoms such as depression, fatigue and sleeping it. Studies in recreational settings in Slovakia also found difficulties. Suicidal behaviour is a significant risk during the methamphetamine to be a popular drug. A survey crash period (Pates and Riley, 2010). conducted in 2005 among attendees of music festivals and a big dance music event found that, in the age group 15–29 years, 27 % had ever used methamphetamine, 19 % in the Psychological and psychiatric effects of long-term past year and 10 % in the past month. amphetamines use
Causal links between amphetamines use and psychiatric Health consequences of amphetamines use symptoms are difficult to establish, as some symptoms and conditions may pre-exist in the user or other factors, such as Research on the health consequences of amphetamines use HIV infection or polydrug use, may act as cofounders. has largely been conducted in countries such as Australia Studies have found, however, that pre-existing psychotic and the United States, where methamphetamine use, symptoms can be greatly exacerbated by subsequent notably crystal methamphetamine smoking, has become an amphetamines use. For example, a Swedish study among important problem. While the findings of these research prisoners (Håkansson et al., 2009) revealed that users of efforts may sometimes be more specific to drug use amphetamines were more likely to exhibit psychiatric patterns that are uncommon in Europe, in many instances symptoms than were heroin or cocaine users. They also they are applicable to users of powder amphetamines, found that many stimulant users had had other psychiatric including injectors. In addition to reports in the problems as well, and drug use exacerbated these international literature, results from recent, sometimes problems. smaller-scale, studies reported by European countries are included in this overview. The most serious psychopathological harms associated with amphetamines use include psychosis, depression, Medical use of amphetamines has been associated with a suicidal behaviour, anxiety and violent behaviour (Darke et number of side-effects including anorexia, insomnia and al., 2008). Psychosis induced by amphetamines is typically headaches, but illicit amphetamines use is associated with transient, involves delusions and hallucinations, and is a broader set of negative consequences (Darke et al., similar to paranoid schizophrenia. It lasts for hours to days, 2008), including psychosis, cardiovascular and and in severe cases may require hospitalisation and cerebrovascular problems, dependence, psychological and medication. Regular users of amphetamines commonly psychiatric problems, infectious diseases and death. For experience various psychotic symptoms, including feelings example, in the Czech Republic, a survey assessing of persecution and auditory, visual and tactile hospitalisations among patients who had been admitted at hallucinations (such as a perception of parasites in the least once for drug use disorders found that for pervitin skin). In contrast to early studies, which attributed the onset (methamphetamine) users, the three most common of psychosis to pre-existing conditions, recent research diagnostic groups — apart from dependency-related shows that amphetamines use may cause psychosis. conditions — included mental and behavioural disorders; Psychosis, however, is not an inevitable consequence of injury, poisoning, other consequences of external causes; amphetamines use, but its likelihood is dramatically and infectious diseases. increased by heavy use of the drug (Darke et al., 2008;
16 Problem amphetamine and methamphetamine use in Europe
Pates and Riley, 2010). Amphetamines users often suffer from depression and have high rates of suicidal ideation Neurocognitive damage and its consequences and attempted suicides. Underlying the effects of amphetamine and methamphetamine are the similarities in chemical structure In Slovakia, specialised dependence centres treating they share with the brain’s natural neurotransmitters methamphetamine users reported a high occurrence of dopamine and norepinephrine (Melichar and Nutt, 2010). psychotic disorders of a schizophrenic character among In the brain, amphetamines affect the monoamine their clients. These disorders were predominantly short-term neurotransmitter systems (dopaminergic, serotonergic, drug-induced psychoses with hallucinations and delusions noradrenergic and glutamatergic) (Nordahl et al., 2003). of persecution, which quickly resolved with abstinence. In a Amphetamines are, however, neurotoxic and can cause few cases, however, long-term treatment with neuroleptic damages that may last for months after cessation of use. medication was necessary. Furthermore, at admission, 46 % Many core behavioural and psychiatric symptoms, including withdrawal, that occur in heavy users of the drug of clients were found to have symptoms of depression are likely to be related to altered monoamine regulation according to the Beck Depression Inventory. Czech experts (Darke et al., 2008). Moreover, cognitive deficits in looked into routine data collected on psychiatric diagnoses methamphetamine users are well-documented: these mainly and found a higher prevalence of psychosis among involve impairments in episodic memory, executive methamphetamine users than among users of other drugs. A functions, information processing speed and small survey among addiction specialists also suggested the need impairments in motor skills, language and for specific treatment procedures in users who experience visuoconstructional abilities (Scott et al., 2007). psychosis or certain psychotic symptoms. Many Neurological and cognitive impairment can reduce users’ methamphetamine users report having experienced anxiety independence in daily life, for example in preparing meals symptoms before starting to use the drug, and still more or managing money. This is further associated with report severe anxiety symptoms since commencing use. depressive symptoms. In addition, as many treatment Users, though, might mistake the symptoms of anxiety for interventions available for amphetamines users are cognitive-based, neuropsychological deficits in substance methamphetamine-induced hyperarousal (Darke et al., users may result in poor treatment outcomes, such as higher 2008). Self-mutilation after amphetamines use sometimes rates of programme rule violation, poor cognitive skill happens in both humans and animals, but is it less common acquisition and dropping out (Scott et al., 2007). Social- among women than among men (Pates and Riley, 2010). cognitive functioning may also be impaired, possibly as a Violent behaviours are also common among result of damage to the frontal lobes. In methamphetamine psychostimulant users, especially among chronic users and users, impaired social functioning is linked with other those with acute intoxication. Such behaviours might also symptoms such as paranoid ideation, depression, accompany psychosis (Darke et al., 2008). Establishing a aggression, and a need to hide, all of which can eventually causal relationship between methamphetamine use and lead to social isolation. This is in contrast to the original violence may, however, be unfounded because most intention of the users to enhance their social interaction. In evidence comes from cross-sectional studies (Tyner and animal experiments, rats and monkeys display similar social Fremouw, 2008). withdrawal, which suggests a physiological basis rather than a wish to hide because of the social undesirability of drug use (Homer et al., 2008). Another important mental health consequence of amphetamines use is dependence. Amphetamines withdrawal symptoms are different from those of depressant drugs, such as opioids or alcohol, where the symptoms are A Latvian study investigated the severity of dependence the opposite of the acute pharmacological effects of these among amphetamines and opioid users, using the Severity drugs. On the contrary, some features of psychostimulant of Dependence Scale, which focuses on the psychological withdrawal symptoms, particularly agitation and components of dependence. The study showed that heroin hyperarousal, mimic those of intoxication. Other symptoms of users experienced a higher level of severity of dependence amphetamines withdrawal include fatigue and inertia, than amphetamines users. hypersomnia followed by protracted insomnia, and an onset of agitation with mood disturbances that range from Both the occurrence and the severity of mental health dysphoria to severe clinical depression (Jenner and problems among amphetamines users are associated with Saunders, 2004). Central nervous system recovery after longer duration of use, more frequent use, dependence hyperstimulation by these drugs is characterised by excessive and injecting (Pates and Riley, 2010). Mental health sleeping, eating and irritability (Pates and Riley, 2010). problems are further associated with schizoid personality
17 EMCDDA 2010 Selected issue
prior to the onset of use, or with a family history of findings remain uncertain (Chang et al., 2007). schizophrenia, especially in the non-transient, psychotic Epidemiological data on the risks associated with the use of condition. Violent behaviours may occur more frequently amphetamines when driving are rare and inconsistent in people with an existing propensity to violence (Darke et (EMCDDA, 2008). Methamphetamine use has been al., 2008). associated with poor oral hygiene, including severe tooth decay and tooth wear (Hamamoto and Rhodus, 2009). Methamphetamine use causes xerostomia (dry mouth) and Cardiovascular and cerebrovascular effects bruxism (teeth clenching and grinding), leading to rampant A review by Kaye et al. (2007) summarises the acute and caries as users neglect their dental hygiene while frequently chronic cardiovascular pathology associated with consuming carbonated sugary beverages. While some amphetamines use. The most common cardiovascular effects studies on amphetamines and pregnancy found insufficient of amphetamines use are an acute increase in heart rate evidence to evaluate the developmental toxicity of and blood pressure, which may abate without further therapeutic amphetamines (Golub et al., 2005), another consequences in the majority of cases. Nevertheless, in the study found a 3.5 fold increased risk of foetal growth context of chronic use or pre-existing cardiovascular restriction among babies of women using methamphetamine pathology, these changes in cardiovascular functioning may during pregnancy (Smith et al., 2006). trigger serious and potentially fatal events. Infectious diseases among amphetamines users Amphetamines users are at elevated risk of cardiac pathology, including serious events such as unstable angina, Little is known about the prevalence of infectious diseases and myocardial ischaemia and infarction. The risk is not among groups that use different types of drugs. It has been likely to be limited to the duration of drug use, because the shown, though, that high levels of sexual risk-taking among chronic cardiovascular pathology associated with amphetamines users (both injectors and non-injectors) may amphetamines use may make the side-effects of the drug use contribute to an increased risk of HIV and sexually more long-lasting. The risks are greatest among chronic transmitted infections (Degenhardt et al., 2010). amphetamines users, and pre-existing cardiac pathology, due to amphetamines use itself or to other factors, increases Infectious diseases such as HIV and hepatitis B or C are the risk of an acute cardiac event. more prevalent among injecting drug users than among the general population or among non-injecting drug users Psychostimulant-induced cerebrovascular problems are also (Mathers et al., 2008; Wiessing et al., 2008a, b). In well recognised. Studies report an increase in the risk of contrast to some countries further east (Russia, Ukraine), ischaemic and haemorrhagic stroke, and a substantially in the central and western parts of the European Union higher associated risk of death linked to such events (Darke amphetamines are almost exclusively purchased in et al., 2008). powder form, associated with lower injecting risks compared to drugs acquired in liquid form (Hartnoll et al., It is impossible to assess the risk of serious cardiac events 2010). Amphetamines injectors may be a group where solely on the basis of dose and level of use, as other factors injecting risk is combined with elevated sexual risk may also play an important role. For this reason, information behaviour. However, this risk combination is not always on potential cardiovascular complications related to reflected in the seroprevalence of infections, as the amphetamines should be targeted to all users, not just predominance of injection-related versus sex-related dependent and chronic users. infection risks may be different in different populations.
Other health effects Most European studies of infectious diseases among users of amphetamines have been conducted on injectors using Other health effects and risks include neurotoxicity (12), risks amphetamines as their main or only drug. These studies associated with driving, dental disease, and maybe foetal show a mixed picture: while some found no difference in growth restriction associated with amphetamines use during infection prevalence, others found a lower prevalence of pregnancy. Alterations in brain structure and chemistry both risk behaviours and HIV and hepatitis infection have been documented in heavy users of illicit among amphetamines injectors than among heroin amphetamines, although the clinical implications of these injectors. Differences in infection prevalence are not
(12) See the box ‘Neurocognitive damage and its consequences’.
18 Problem amphetamine and methamphetamine use in Europe
necessarily due to the drugs as such, but may be due to In the United Kingdom’s unlinked anonymous surveillance other factors, such as isolated networks of lower-risk drug system, where injecting drug users in contact with services are injecting groups within the injecting population (Shaw et sampled in repeated surveys, injectors of crack cocaine, al., 2010). cocaine powder and amphetamines were more likely than injectors of other drugs to self-report having shared needles in In the Czech Republic, a national hepatitis C virus (HCV) the past four weeks (HPA, 2009). As HIV prevalence in this study found no difference in the estimated incidence of study was very low (around 1 %), this difference in risk HCV infection between ‘pervitin’ (methamphetamine) behaviours did not translate into a difference in HIV infections. users and opioid users, after adjustment for the period of injecting drug use. Routine infectious disease testing data from low-threshold facilities, however, as well as the data available from the register of treatment demands, suggest Preventing and reducing harms related to that pervitin users may have a lower incidence of HCV. amphetamines injecting This difference, though, may be attributable to the younger average age and shorter history of injecting Interventions to reduce drug-related health harms among amphetamines injectors focus on preventing injecting- drug use of pervitin users in those samples. In related infections. However, few amphetamines-specific comparison to the general population and to opioid measures exist, and responses rely mainly on what is users, pervitin users report a higher rate of sexual risk known from HIV prevention among opioid users. behaviour, making them more vulnerable to sexually Interventions offered to injecting amphetamines users are transmitted infections. similar to those provided for injectors of other drugs and are delivered in the same settings. In general, these Slovakia reported that there is a significantly lower interventions include the distribution of leaflets describing prevalence of HCV (likely also reflecting different incidence) the risks of infectious diseases and other health problems; among users injecting methamphetamines (26 % testing practical skills in connection with safer drug use; needle antibody positive) compared with those injecting opioids and syringe programmes; safer sex education and condom (59 % positive), although the data were not adjusted for the promotion; referral to voluntary counselling and testing for length of use. Furthermore, the lower frequency of injecting infections; and referral to drug treatment as well as other by amphetamines users compared to heroin users results, on health care as needed (Grund et al., 2010a). average, in a significantly lower risk of bloodborne Interventions may also reflect local amphetamines use transmission among amphetamines injectors over a given patterns. For example, a new intervention developed and period of injecting. In the opinion of the Slovak experts, this tested at low-threshold agencies in the Czech Republic difference in injecting frequency might explain a large part supports non-injecting and less harmful patterns of stimulant of the difference in HCV prevalence. use by distributing empty gelatine capsules to pervitin (methamphetamine) users. The users may fill the capsules A study in Estonia compared 256 primary opioid (fentanyl) with pervitin powder and swallow them. Taken orally, injectors with 75 primary amphetamines injectors (Talu et amphetamines have a high bioavailability, and the al., 2010). One of the main findings was that the prevalence capsules enable the user to avoid the bitter taste of pervitin. of HIV among those who injected amphetamines (27 %) was Clients perceived preparing the capsules easy and showed less than half that among those who injected fentanyl increasing interest in this alternative route of administration. (62 %). Self-reported risk behaviours were consistent with the More research is still needed to evaluate its benefits and seroprevalence findings and less common among potential harms. amphetamines users than among fentanyl users. Fentanyl Risk behaviours are also associated with the characteristics users had injected almost five times more frequently in the of the drug users’ social networks and their environments. last four weeks, they had shared needles or syringes with To prevent and reduce harms related to amphetamines persons who were known to be HIV-positive four times more injecting, a combination of interventions may be required, often, and they filled their syringes from other used syringes aiming at reducing personal risk behaviours, changing almost three times more often. While levels of unprotected social network norms (about risk boundaries or equipment sex were not statistically different among amphetamines and sharing) through peer education, addressing the injecting fentanyl users, amphetamines injectors had more sexual process (e.g. by promoting the use of one-piece instead of partners in the past 12 months. two-piece syringes) and structural factors (e.g. by increasing the availability of sterile syringes or providing A study in Latvia found also lower levels of prevalence of hygienic injecting environments as an alternative to public HIV, HCV and hepatitis B virus among amphetamines injecting). injectors than among opioid injectors.
19 EMCDDA 2010 Selected issue
Deaths related to amphetamines interpreted with caution because of the very low number (nine) of deaths reported during the follow-up period. Little is known about deaths related directly (acute poisoning) or indirectly to amphetamines. A recent Only three of the studies reviewed by Singleton et al. systematic review suggests that investigating the morbidity described the specific causes of death. These mainly and mortality associated with amphetamines use should be included heroin overdose and accidents or injuries. In the a research priority and that cohort studies with long-term Czech Republic, pervitin users appear to show a higher follow-up and data that are linked to mortality statistics are rate of deaths caused by external factors, especially needed (Singleton et al., 2009). This is particularly suicides, when compared to opioid users. A study among important for countries where problematic amphetamines drug users from the Netherlands found higher mortality use is prevalent or increasing. rates among injectors than among non-injectors, and among those who had used amphetamines for five years or A comprehensive review of studies on mortality among longer (van Haastrecht et al., 1996). Estimating the dependent and problematic amphetamines users included mortality directly associated with amphetamines is eight cohort studies in Australia, Thailand, Sweden, Finland, complicated by polydrug use (i.e. concurrent use of mainly Netherlands, Czech Republic (Singleton et al., 2009). The heroin and cocaine). estimated crude mortality ratio ranged from zero in Australia to 2.95 per 1 000 person years in Thailand, and, among An overview of drug-related deaths in the United Kingdom the European countries, from 0.49 to 2.89 per 1 000 between 1997 and 2007 identified 832 deaths with positive person years. The standardised mortality ratio (the ratio of tests for amphetamine or methamphetamine (Schifano et al., observed deaths to the expected deaths in the general 2010). Only in 13 % of these fatalities was just one drug population) was estimated in the Czech cohort study only found at post mortem or implicated. In these cases, the most (6.22 overall). A study in the Czech Republic also found that common causes of death were due to well-known medical the overall mortality rate of pervitin users was approximately consequences of amphetamines use such as cerebral half that among heroin users (4.9 cases versus 8.6 cases per haemorrhage and acute hypertensive crisis (70 %), pre- 1 000 person year, respectively). existing cardiovascular and cardiopulmonary conditions (17 %) and risky behaviour while intoxicated with In Latvia, a mortality cohort study enrolled 551 patients who amphetamines (8 %). In the other cases, the drugs entered treatment for amphetamines use between 1999 and mentioned in addition to amphetamines included heroin or 2006. For the cohort, the crude mortality rate was 5.69 per morphine (39 %), alcohol (20 %), methadone (17 %), 1 000 person years, and the standardised mortality rate cocaine (13 %). Methamphetamine was identified in only 14 was 3.28 per 1 000 person years. These rates have to be out of the 832 cases.
20 Part 2: Problem amphetamines use in Europe
Amphetamines use exists to some extent in all European Figure 3: Problematic use of amphetamines in Europe countries, but only in a few is it reported as a major component of the drug problem (Figure 3). This section of Countries with problematic the report reviews the available information regarding amphetamines use problem amphetamines use and the related treatment Mainly amphetamine Mainly methamphetamine responses in four geographical regions and sub-regions of Both drugs present Europe: western and southern Europe, where, in many countries, amphetamines users account for a small fraction Other countries Reporting additional information of problem drug users; northern Europe, where or covered in some detail amphetamines use is sometimes a long-established problem Not covered in detail and is still today a key element of the drug situation; eastern and central Europe, where there are very different levels of amphetamines problems, but with increasing trends in several countries, with a special focus on the Czech Republic and Slovakia, as countries that have a specific historical context and comparable amphetamines problems.
Western and southern Europe
There is no single history of amphetamines use in western and southern Europe, as during the twentieth century it developed along different timelines across these regions. In addition, historical information is available only for a few of these countries. In the absence of information on southern European countries, reports of past amphetamines use in the Netherlands and the United Kingdom must serve to illustrate NB: This map highlights those countries with significant problem 13 the history of amphetamines in western Europe ( ). amphetamines use, grouped according to the relative levels of amphetamine and methamphetamine use by a multi-indicator approach. Other countries During World War II, amphetamine and methamphetamine contributing to the special data collection (or in the case of Germany, tablets were widely distributed to members of the armed showing significant treatment demand related to these drugs) are also indicated. forces on both sides of the conflict. The literature specifically mentions German soldiers, but servicemen of other nations also received amphetamines pills. Three-milligram In the United Kingdom, after the war, amphetamines were methamphetamine pills under the name pervitin were liberally prescribed, with ready availability of over-the- already available in Germany from 1938, and appear to counter preparations. This policy was later changed, and have been widely distributed among the armed forces. In the substances became subject to prescription control in 1941, this substance became more controlled in that country, 1957. The 1960s saw an increase in amphetamines use in due to the long recovery periods that soldiers needed after Europe, as the drugs were taken up by new groups of its use and some cases of abuse. Thereafter, German recreational users. A Dutch ethnographic study on problem military doctors prescribed it more cautiously.
(13) With further information on the use of amphetamines by armed forces in the Second World War, available on Wikipedia.
21 EMCDDA 2010 Selected issue
drug users suggests that amphetamine and entering treatment for primary use of amphetamines methamphetamine were used in specifi c drug scenes, remained mainly stable in most western and southern together with other drugs, in the Netherlands since 1962. In European countries. the United Kingdom, recreational use of diverted amphetamines is said to have ‘reached epidemic Low prevalence of amphetamines use among problem drug proportions’ in the 1960s, and towards the end of the users has also been reported in various national and local decade there were some reports of methamphetamine studies. The Dutch ‘Amsterdam Cohort Study’ revealed that injecting on the London drug scene. neither amphetamines alone (around 1 %) nor the combination of amphetamines with heroin or cocaine (about During the 1970s, many countries imposed or tightened their 8 %) was prevalent among the studied population of control on amphetamines possession and/or use. In 1971, problem drug users. Similarly, in Wales, a study in 2008 the United Kingdom scheduled non-injectable amphetamines among the users of a needle exchange programme found as class B and injectable amphetamines as class A under its that 8 % of clients used amphetamines, while Luxembourg Drug Misuse Act. However, due to the focus on heroin use reports that only 1 % of problem drug users sampled in during the 1970s and 1980s, information about various treatment and non-treatment settings consider amphetamines use in the United Kingdom at that time is amphetamines as their main drug. Compared with the low scarce. It is known, though, that amphetamine remained levels of amphetamines use reported by problem drug users popular in the nightlife scene, and pills were replaced by in this part of Europe, a survey carried out in 2004 stands amphetamine powder. In 1976, the Netherlands issued its out as an exception, with almost half the injectors (48 %) ‘Amphetamine Decree’, placing amphetamine and methamphetamine under the Opium Act as illegal drugs. As Figure 4: Relative importance of amphetamines, opioids and in the United Kingdom, amphetamines were ‘not a priority of cocaine clients entering treatment in selected European countries drugs combat’, partly as they were not perceived to cause serious problems and partly because of the focus on opioids. Amphetamines In these countries, the available information suggests that Cocaine Opioids Finland though amphetamines use continued during the 1970s and 1980s, it was overshadowed by the rising use of heroin. In Norway Sweden the 1990s, however, with the development of the electronic Estonia music scenes and the diffusion of synthetic drugs, amphetamines use surged. Latvia
Lithuania Denmark Problem amphetamines use today
United Netherlands In the majority of western and southern European countries, Kingdom
problem amphetamines use represents a small fraction of Germany Slovakia Belgium Czech problem drug use and primary amphetamines users account Republic
for less than 5 % of those who enter treatment for opioids, Hungary cocaine or amphetamines problems in most countries of this Austria region (14). The fi gure is higher only in Belgium (14 %),
Germany (13 %) and the Netherlands (10 %) (Figure 4). Bulgaria Most amphetamines clients enter treatment in outpatient services. Their mean age is 29.1 years, and they started using amphetamines at an average age of 19.3 years. The NB: The pie charts show the number of amphetamines, opioids and cocaine users entering specialised drug treatment as a proportion of the total number male to female ratio among amphetamines users in this of those reporting one of these three drugs as their primary substance. Data group is about 2:1. Among amphetamines users in these are shown only for countries where amphetamines (or non-cocaine stimulants countries, injecting ranges from zero (Ireland, Italy, Cyprus, in the case of Germany and Lithuania) account for at least 2 % of those entering treatment for these three drugs. Based on Table TDI-5 (part ii) in the Luxembourg, Austria) to 24 % (United Kingdom). Between 2010 statistical bulletin and non-TDI data for Norway. 2003 and 2008, the number and proportion of clients Source: National focal points.
(14) Data on treatment prevalence — on all drug users in treatment — may yield a slightly different breakdown by primary drug: see Table TDI-38 in the 2010 statistical bulletin.
22 Problem amphetamine and methamphetamine use in Europe
attending a needle and syringe programme in Antwerp, treatment. In some cases, amphetamines users, especially Belgium, reporting use of amphetamines. socially integrated ones, may regard these treatment services as suitable only for users of ‘problem drugs’ such as A study conducted in Luxembourg showed that heroin (EMCDDA, 2009). They may also believe that amphetamines use may have been part of problem drug treatment facilities are unable to adequately deal with the users’ consumption careers in the past, but is less often part complexities of amphetamines dependence (e.g. Vincent et of their current drug use patterns. Among sampled al., 1999; Wright et al., 1999). For these reasons, they may participants, both from treatment and other settings (low- be reluctant to seek treatment for their drug problems. threshold facilities and prisons), 57 % had ever taken amphetamines, but less than 5 % — mostly participants Besides the general outpatient psychosocial interventions, under the age of 30 — reported taking the drug in the past residential treatment or referral to psychiatric services are two months. Among respondents from prisons who reported available for serious psychiatric comorbidity associated with having used amphetamines, 86 % had not used the problematic amphetamines use. The United Kingdom is the substance in the last two years. only country where substitution therapy with dexamphetamine is available. Dexamphetamine has long Treatment options for problem amphetamines use been available for the treatment of highly problematic users of amphetamines in England and Wales, where it may be In western and southern European countries, specific prescribed by any doctor. Information on this practice is treatment programmes for amphetamines users are rare and limited. A survey of pharmacy services conducted over 10 treatment systems have specialised in responding to the years ago estimated that 900 to 1 000 clients were needs of opioid users, especially with opioid substitution receiving this treatment (Strang and Sheridan, 1997). Most
Treatment for amphetamines problems Short-term detoxification and a range of outpatient psychosocial interventions, such as cognitive behavioural The number of drug users reported entering treatment for therapy, are provided, and pharmacological treatment of primary amphetamines use in Europe is relatively small (1), symptoms, as well as long-term residential treatment, is amounting to about 19 000 across 28 countries in 2008, half available for the more severe cases. Unfortunately, as reported of them entering drug treatment for the first time in their lives. In by professionals, psychiatric problems are frequent and difficult addition, amphetamines are reported as a secondary drug, to handle within the therapeutic context. often in combination with opioids, by around 36 000 treatment entrants who report other primary drugs. Specific quality assessment measures for the treatment of amphetamines users have been reported by a number of Amphetamines withdrawal is not considered life-threatening, Member States. In countries where problem amphetamine use and successful detoxification is possible (Jenner and Saunders, has been widespread for a long time, quality assurance is 2004). Apart from a few studies showing some effectiveness integrated in general drug treatment programmes. for fluoxetine (an antidepressant) and imipramine (an adrenergic uptake inhibitor; Shoptaw et al., 2009a, b; Research on treatment options for drug dependence has Srisurapanont et al., 2001), most pharmacological approaches historically focused on the needs of opioid users, but research for treating amphetamines problems are still under development in the field of amphetamine and methamphetamine is growing, and evaluation. Contingency management (2), however, has especially regarding potential substitution therapy. Such been shown to result in a reduction of use while in treatment research is urgently needed, as professionals report and in abstinence at short-term follow-up (Roll et al., 2006). experiencing therapeutic difficulties with amphetamines users. Sharing of best practice can also play an important role in Despite the lack of effective pharmacological treatment options improving care, particularly in countries lacking specialised for amphetamines users to reduce use or maintain abstinence, treatment services for stimulant users. some Member States have developed specific interventions targeting problem amphetamines users.
(1) In a small number of countries, it is not possible to distinguish amphetamines users in the treatment data, as these are reported as users of ‘stimulants other than cocaine’. Data from the other countries indicate, however, that amphetamines users may represent the vast majority (86 %) of this category, and they are included in the amphetamines data for analysis. (2) Contingency management typically aims to reduce the reinforcing effects of drugs by rewarding abstinence with vouchers or other incentives that increase progressively, but may also decrease or be lost.
23 EMCDDA 2010 Selected issue
prescriptions were issued by doctors working in hospitals or reportedly higher rates. The user groups expanded beyond clinics, almost all of whom were in the National Health artists and criminals, and the drug gained ground in Service (NHS). A survey of 265 NHS specialist services, recreational settings as well — young people in parties and carried out in 2000, revealed that dexamphetamine persons wishing to improve their sexual performance. prescribing was available in about a third of the services surveyed (Rosenberg et al., 2002). Due to a lack of Finland, in 1941, received a large supply of demonstrated effectiveness, however, the United Kingdom methamphetamine pills from Germany in support of the guidelines on clinical management of drug dependence Continuation War against the Soviet Union (1941–44). recommend against substitute prescribing of When the ensuing offensive was at its height, 850 000 dexamphetamine (NTA, 2007). pervitin pills were available to Finnish front-line soldiers, commanders and reconnaissance patrols as well as medical crops. Pervitin was used to reduce the need for Northern Europe sleep and sensitivity to hunger, and to improve the physical performance of soldiers. It also dulled their Problem amphetamines use lies at the heart of the drug sensitivity to pain, while heightening their alertness, problem in Sweden and Finland, while in the neighbouring increasing their self-confidence and concentration, and countries of Denmark and Norway, levels of use of these lowering their threshold to taking risks. However, the substances in the general population are above the side-effects of this drug soon became obvious. European average. Amphetamines use in northern Europe Sleeplessness due to pervitin use could induce paranoia, has some specific historical characteristics, which can be hallucinations and aggressive behaviour, while long-term described in some detail for Sweden (Goldberg, 1968) and use increased the likelihood of substance addiction and Finland. could even lead to fatalities. Amphetamine drugs were introduced in Sweden in 1938 under the names benzedrine (amphetamine) and pervitin During and after the war, many Finnish families used various (methamphetamine). In the following two to three years, the prescription amphetamine and methamphetamine products substances were widely recommended in the Swedish mass (benzedrine, stimulan, pervitin and beramin). Amphetamines media as a ‘pep pill’ for all sorts of people from students to were particularly popular among drivers and students. The tired housewives, and soon reached their broadest public. substances were readily prescribed, and as Sweden was probably the first country in Europe to conduct methamphetamine was not considered a narcotic, it was not representative surveys of students’ drug use. In studies monitored. Problem drug use, at that time, was equated carried out in 1938–1941, about 70–80 % of students mainly with the use of opioids in Finland. However, in the reported lifetime prevalence of amphetamines use. From mid-1950s, as opioid use decreased, amphetamine use 1939, amphetamines were no longer available in Sweden began to increase, possibly as a result of the influence of without a doctor’s prescription; which stabilised levels of use Sweden on the post-war Finnish generation. Amphetamine, for one year, before they started to rise again. In 1942/43, even at that time, was often used intravenously, and the first the number of amphetamine users was estimated to be cases of problem amphetamines use in Finland were 200 000, or 3 % of the adult population, most of whom documented. Postulated reasons for this include relatively were occasional users, though 7 200 were estimated to use easy access to liquid amphetamine and Finnish drug use at least once a week, with about 1 % (200) of all practice’s history of favouring intravenous drug use in order amphetamine users using between 10 and 100 pills a day. to experience the strongest effects. However, it was not until In 1943, as awareness increased about the negative the late 1960s, that amphetamine became more widely side-effects of amphetamines, a warning was issued to known in Finland, and amphetamine began to be smuggled Swedish physicians, and the mass media started to point out into Finland. the risks of uncontrolled use. This led to sales decreasing by 40–60 %. The following year, Sweden placed amphetamine In 1974–75, Sweden witnessed the arrival of heroin in the on its National Narcotic Drugs List. In spite of this, Stockholm area, where it became displaced amphetamine widespread use of these substances continued until the early as the drug of choice among injectors. Outside the capital, 1950s, when it became more closely associated with certain however, amphetamine retained its popularity. In the 1990s, social groups such as artists and criminals. some countries in the region experienced a further increase in amphetamines use, both in recreational settings and In 1960, Sweden estimated that there were 1 000 among problem drug users. In Finland, amphetamine use amphetamine injectors in the country. The spread of has outstripped opioid use since 1997, with use and amphetamine use in Sweden continued afterwards at drug-related harm probably peaking in the mid-2000s.
24 Problem amphetamine and methamphetamine use in Europe
Problem amphetamines use today Of the 6 350 drug users who entered prison in Sweden in 2006, 4 750 were diagnosed with a severe drug Finland has produced an estimate of 14 500– dependence problem. Most of them (73 %) were primary 19 000 problem drug users in 2005 (15). Of these, 75–80 % amphetamines users, which is a much higher proportion used amphetamine as their primary drug, corresponding to than is found among drug using populations outside prison. 16 296 (12 000–22 000) problem amphetamine users, or These amphetamines users exhibited an intensive use 4.7 (3.4–6.3) per 1 000 inhabitants aged 15–64. Although pattern: 61 % were daily users, with an average 23 days of subnational studies suggest lower prevalence levels of use in the past 30 days, and most of them (70 %) injected problem drug use in eastern and northern Finland, the the drug. Many of them reported also using other drugs in proportion of amphetamine users is roughly the same across the past 30 days (38 %), mainly cannabis (36 %) and the country. In the greater Helsinki area, the estimated tranquillisers (22 %), or were binge alcohol drinkers (12 %). number of problem amphetamine users was 4 000–6 000 The use of opioids, cocaine or hallucinogens was rare. in 2005. The estimated prevalence of problem amphetamine Amphetamines users were older, came from a more rural use in Finland increased steadily between 1997 and 2005. and non-immigrant background, and reported psychiatric symptoms and problems more often and previous inpatient Primary users of amphetamines mostly enter treatment in detoxification less often than users of heroin or other drugs. outpatient centres, although in Finland and Sweden, inpatient centres play an important role (16). Amphetamine A Norwegian study interviewing clients of a needle users represent less than a fifth of treatment entrants citing distribution facility in Oslo found that in the period between opioids, cocaine or amphetamines as their primary drug in 1999 and 2008, 63 % of the interviewees used Denmark (17 %), around a quarter in Norway (25 %) (17) amphetamines on 14.5 days on average during the last and Finland (26 %) and almost half in Sweden (49 %) month. The distinction between amphetamine and (Figure 4). Injecting drug use is reported by a clear majority methamphetamine was not possible, as the users were unable of amphetamines clients attending outpatient centres in to distinguish between the two. A trend analysis revealed an Finland (82 %) and Sweden (67 %), but not in Denmark increase both in the proportion reporting amphetamines use (4 %), thereby highlighting differences in patterns of during this period (from 59 % to 68 %) and in the number of amphetamines use between these countries. days of amphetamines injecting (from 12.5 to 16.6 days). While the number of amphetamines users entering treatment High proportions of amphetamines users reported polydrug for the first time has remained relatively stable between use, with 77 % having also used cannabis and 20 % cocaine; 2003 and 2008 in Sweden and Denmark, Finland reports a 75 % having injected heroin in the last month. decrease in both the number and the proportion of new amphetamines clients (18). Polydrug use appears to be a common pattern among problem amphetamines users. A Finnish study found that Sweden reports the highest average age of amphetamines amphetamines users usually engage in polydrug use to clients in Europe (35 years), followed by Finland (30 years), achieve specific pharmacological effects. Alcohol, while in Denmark clients for this drug are younger (26 cannabis, medications or buprenorphine were often used years). Sweden (1.5:1) and Finland (1.6:1) report two of the either to boost or alter the effects of amphetamines or to lowest male to female ratios among amphetamines clients in enable sleep following extended hours of hyperactivity and Europe. Overall, female amphetamines clients are younger wakefulness. Moreover, amphetamines and opioids may than their male counterparts. In Sweden, 37 % and in be used intermittently, either when the other drug is not Finland 25 % of all women entering outpatient treatment use available or to ‘treat’ dependence on one drug by the amphetamines as their primary drug, compared to 27 % other drug. Among injecting drug users attending a needle and 17 % of men, respectively. In these two countries, exchange programme in Malmo (Sweden), 57 % of the especially among women in Sweden, the duration between clients considered amphetamines to be their main drug. first use and first treatment is long compared to the rest of The study, which focused mainly on illicit buprenorphine, Europe (19). also found that amphetamines users used buprenorphine
(15) The problem drug use estimate in Finland must be interpreted with caution when comparing it with figures from other countries. This is because the Finnish estimates may be based on a broader definition than that of the EMCDDA (and of other countries) and may include some occasional users as well. (16) See Table TDI-19 (part ii) and (part iv) in the 2010 statistical bulletin. (17) Based on non-TDI data for Norway. (18) See Table TDI-3 in the 2010 statistical bulletin. (19) See Table TDI-103 (part iii) in the 2010 statistical bulletin.
25 EMCDDA 2010 Selected issue
more often than heroin users. In another Swedish study by the same criminal groups. Methamphetamine smoking carried out in 2007/08 among injecting drug users has not been reported in Sweden. recruited from public settings in Stockholm, 47 % of respondents identified amphetamines as the drug they had A series of Finnish studies found that amphetamines users used most frequently in the last 12 months. Polydrug use usually take 0.5 to 5 grams of the drug per day, depending was common and some primary users of other drugs used on the purity and individual tolerance levels. As the price of amphetamines too. a gram of amphetamines is around EUR 30, problem amphetamines use can be costly and is often associated Norwegian emergency psychiatry data from 2003 and with petty theft. 2006, mainly on people with acute psychosis characterised by uncontrolled behaviour and suicidality, showed that of Treatment options for problem amphetamines use those who tested positive for amphetamines, most (in 2003) or all (in 2006) were positive for methamphetamine. While In Sweden, amphetamine is the drug historically most this may suggest that methamphetamine plays more of a role commonly associated with problem drug use and treatment in psychosis than amphetamine, it may also reflect the of drug dependence has been developed to cater for the underlying prevalence of use of the two drugs. Toxicological needs of amphetamine users. The main treatment approach data from the National Institute of Public Health provides is residential treatment using the 12-step Minnesota model. evidence of the increasing presence of methamphetamine in Problem amphetamine users attend a 6 month 12-step Norway. Over the period 2000–08, amphetamines were programme, and then attend Narcotics Anonymous detected in 3–5 % of urine samples from correctional meetings for several years. Residential treatment is usually facilities 18–28 % of blood samples from drivers suspected provided by private organisations, but is covered by the of driving under the influence, and 5–8 % of autopsy national health insurance. Clients with less problematic use samples, with data from all three sources pointing to the receive psychosocial treatment, namely cognitive same changes in the stimulants market. For all categories, as behavioural treatment and motivational interviewing, on an a proportion of all cases involving amphetamines, those with outpatient basis. A clinical trial with naltrexone, a non- methamphetamine have risen from being almost zero selective opioid antagonist, to reduce craving for and use of around the turn of the millennium to 54 % (prisoners), 69 % amphetamines has been conducted with positive outcomes (drivers), and 80 % (autopsies) of all tests in 2008. These reported. laboratory results are mirrored by the number of seizures of these two substances. In 2000, methamphetamine only In Finland, problem amphetamines users are sometimes accounted for 6 % of the total seizures of the two drugs, admitted to psychiatric hospitals to receive treatment for rising to 44 % in 2008, and as high as 68 % in the first six amphetamine psychosis. However, no long-term psychiatric months of 2009. care is available for such users. Psychosocial interventions and short-term detoxification are available, but access to In Sweden, analysis of biological samples taken from people continued treatment is much more limited. When seeking suspected of minor drug offences in 2009 showed that treatment, some amphetamines users are thought to methamphetamine was found in about 1 % of the tests, 16 % emphasise their use of opioids in order to receive long-term of the tests revealed amphetamine alone, and both drugs opioid substitution treatment. were detected in a further 13 % of tests. The prevalence of any amphetamines among those tested also declined from Norway reports that problem amphetamines users are often 44 % in 2006 to 34 % in 2009. However, between 2007 difficult to reach with therapeutic measures and many of and 2008, the proportion with both drugs present increased them do not seek help. However, this group still constitutes a about three-fold to 12 %. While this appears to indicate an large proportion of those admitted to emergency psychiatric increase in the use of methamphetamine at the expense of treatment. amphetamine, further interpretation is difficult, as amphetamine is a metabolic breakdown product of Eastern and central Europe methamphetamine (Schepers et al., 2003). Other data from the police and customs in Sweden also show an increase in In several eastern and central European countries, various methamphetamine use in most parts of the country. Many data sources suggest that the use of amphetamines users in Sweden are reported to find methamphetamine represents a significant part of overall problem drug use. interchangeable with amphetamine, but some view This section focuses on five countries: Estonia, Hungary, methamphetamine as stronger and better. The two Latvia, Lithuania and Poland in this region; the Czech substances probably cost about the same and are distributed Republic and Slovakia are discussed later. Unfortunately,
26 Problem amphetamine and methamphetamine use in Europe
little has been reported regarding the social history of clients report injecting the drug, while 23 % do so in amphetamines use in these five countries. Available studies Hungary. mostly place the first appearance of amphetamines use in the 1990s. For example, a Polish study looked at the Annual surveys have been conducted since 2006 among emergence of amphetamines use in Gdansk (Sękiewicz, drug users recruited from non-treatment settings in Riga, the 2001), a city that has been characterized as being the first capital of Latvia. In 2009, the most commonly used drug to be influenced by new ‘western lifestyle’ trends. It found was amphetamines: 65 % of the respondents reported using that the Polish drug scene was dominated by ‘kompot’ (also it in the past 30 days, almost all (98 %) by injection. The known as Polish heroin) in the 1970s and 1980s. The early prevalence of amphetamines use decreased with age. 1990s saw the rise of problems related to the use of Amphetamines users were less likely than heroin users to amphetamines. Although the number of amphetamines users switch to other drugs. in Gdansk in contact with treatment agencies increased greatly in the 1990s, a snowball survey suggested that only In Latvia, amphetamine has been detected in various 4 % of all amphetamines users had contact with the biological samples from police sources, first in 1991 and treatment system, as opposed to about half of the heroin increasingly since 1998. Methamphetamine was first users. Amphetamines users were also more socially detected in 1999 and increasingly since then. Evidence of integrated than heroin users. polydrug use is common among amphetamines users tested, with almost 80 % of the samples showing signs of amphetamine or methamphetamine use testing positive for at Problem amphetamines use today least one other substance. The drugs most commonly detected in the presence of amphetamines are opioids, Primary use of amphetamines was reported by between 3 % cannabis and benzodiazepines and/or barbiturates. (Lithuania) and 41 % (Hungary) of treatment entrants declaring opioids, cocaine or amphetamines as their An Estonian study among injecting drug users in two cities primary drug (Figure 4). The number and proportion of found amphetamine injecting quite widespread. In 2007, amphetamines clients entering treatment for the first time in half of the injecting drug users in Tallinn and a quarter of their lives increased rapidly in Latvia (from 1 % in 2000, to those in Kohtla-Jarve reported injecting amphetamine in the 16 % in 2003 and 38 % in 2008); the percentage also past four weeks and a third and 16 %, respectively, increased in Hungary, but with decreasing absolute considered amphetamine as their primary drug. A survey numbers. carried out in 2008 among clients of syringe exchange Most primary users of amphetamines entering treatment do services found that over half of them had injected so in outpatient settings. In Hungary, most amphetamines amphetamine in the past four weeks. Another study found clients are sent to treatment by the criminal justice system as that 63 % of amphetamine injectors had injected only this diversion from punishment. In Latvia, most are self-referred drug within the last four weeks, while the remainder had or referred by medical services. also injected other drugs. Among prison inmates, more than two-thirds reported using amphetamine while incarcerated The average age of amphetamines users entering treatment in 2006 and 2008. in these countries is low compared to other countries: between 22 (Estonia) and 28 years old (Hungary) A third study in Estonia used respondent-driven sampling depending on the country. Overall, female amphetamines (Talu et al., 2010) to compare HIV-related risks among clients are younger than their male counterparts (20). On amphetamine versus opioid (fentanyl) injectors (21). The study average, primary amphetamines clients report their first use found that primary amphetamine users were more likely than of the drug at between 17.4 years (Estonia) and 21.5 years fentanyl users to be Estonian, to have a shorter injecting (Hungary). career, and to have health insurance, and they were less likely to be daily injectors in the past four weeks and to have Females account for about a third of those entering been arrested in the past 12 months. The study also found treatment for primary amphetamines use, a higher that, in the past four weeks, almost half of the primary proportion than among opioid or cocaine clients. In Estonia, fentanyl users had also used amphetamine, while a quarter Lithuania and Latvia, more than 60 % of amphetamines of primary amphetamine users had also used fentanyl.
(20) See Table TDI-103 (part iii) in the 2010 statistical bulletin. (21) See ‘Infectious diseases among amphetamines users’.
27 EMCDDA 2010 Selected issue
A Hungarian study on out-of-treatment injecting drug users in Budapest, self-identified either as Roma or non-Roma, Amphetamine injection in countries bordering found that amphetamine had the highest levels of both the European Union lifetime and past-30-day prevalence in this group: in the past 30 days, 83 % of Roma and 61 % of non-Roma In Ukraine, reports indicate a high prevalence of both injectors had used amphetamine, mostly with other methamphetamine and methcathinone (a stimulant drug substances. Another Hungarian survey conducted between manufactured from pseudoephedrine) use among injecting drug users and a growing concern about it among 2006 and 2008 among clients of a syringe exchange professionals (Grund et al., 2010a). Stimulants were programme in Budapest showed that amphetamine was the reported as the second most popular drug in a study by most frequently reported primary substance, namely by Balakireva et al. (2006), and there was a 69 % prevalence 58 % of males and 64 % of females. Amphetamine was of past-month use among of out-of treatment injecting drug used more frequently by younger participants and women. users in a study by Booth et al. (2008). A worrying trend A third study, conducted in 2005/06 among injecting drug was found in case of methcathinone (called locally users recruited in a different area of Budapest, found that in ‘boltushka’), which seemed to be increasing in popularity the past 30 days, 52 % injected heroin only, 20 % among very young and poor users in the city of Odessa. amphetamine only, and 27 % both heroin and amphetamine Manufactured from phenylpropanolamine in the absence of (Gyarmathy et al., 2009b). None of those interviewed ephedrine or pseudoephedrine, it might have many reported using methamphetamine or tested positive for its negative health impacts, including haemorrhagic stroke metabolites (Gyarmathy et al., 2009a). (Chintalova-Dallas et al., 2009; Horwitz et al., 2000). Most injecting drug users in Russia inject only heroin, but A 2008 survey in various Polish low-threshold facilities amphetamines are reported to be the second most revealed that in the past 30 days, 76 % of the respondents frequently injected drug. In a study involving injecting drug (who were mainly in their twenties) had used opioids and users from 11 Russian cities, depending on location 61 % had used amphetamines. Over two-thirds of between 15 % and 89 % of the participants reported amphetamines users reported using the drug at least once a having injected stimulants at some point in their lives, with week, and 11 % used it daily. The most prevalent route of from zero to 43 % of them doing so in the past 30 days. administration of amphetamines was injecting (85 %), while Altogether, 90 % of the participants reported having 20 % snorted it, 7 % used it orally and 1 % smoked the injecting heroin in the past 30 days (Borodkina et al., drug. Altogether, 17 % of respondents identified 2005). Few injectors seem to use amphetamines only (e.g. amphetamines as the drug causing them the most problems. less than 5 % of injecting drug users in St Petersburg; Grund et al., 2010b). In a 2007 survey among Polish prison inmates, 39 % of respondents reported ever in lifetime use of amphetamines, 15 % use in the last year and 5 % use in the last 30 days. Last year prevalence of amphetamines use decreased covers diagnosis, the indicated structure of medically considerably with age. assisted and drug-free treatment, and other therapies and rehabilitation.
Treatment options for problem amphetamines use Czech Republic and Slovakia Many countries in this group have experienced surges of problem amphetamines use only recently. Thus, their Methamphetamine use, including use of crystal treatment systems are still largely organised to serve the methamphetamine, has developed as a major problem in needs of problem opioid users, and they appear to several regions of the world, but has had up to now limited experience difficulties and shortcomings in addressing the diffusion in Europe. A different methamphetamine problem, needs of amphetamines users. however, developed in the former Czechoslovakia, and is still central to the drugs problem of the Czech Republic and In Estonia, treatment options for problem amphetamines Slovakia (Grund et al., 2010b; ACMD, 2005). users are also reported to be relatively limited. However, with a planned update of the national drug strategy in In the former Czechoslovakia, non-alcohol drug use 2010, more attention will be given to this group. In Hungary consisted mainly of diverted medications, both stimulants the first professional protocol dealing specifically with the and depressants. In the 1950s, benzedrine problem use treatment of amphetamines users was published by the and dependence was considered the most serious non- Ministry of Health at the beginning of 2008. The protocol alcohol substance dependence problem. At about this time,
28 Problem amphetamine and methamphetamine use in Europe
non-medical use of other preparations containing (20 700–21 800), corresponding to a prevalence of 2.87 amphetamines or amphetamines precursors was also per 1 000 inhabitants aged 15–64 years (2.79–2.94 per reported, including yastil (an asthma medication containing 1 000), and showing no significant change during the ephedrine). Sometimes, benzedrine and yastil were used period 2001 to 2008 (22). Methamphetamine users together. As yastil’s non-medical use was also linked to constitute about two-thirds of the problem drug users in the psychotic symptomatology, the drug was soon made country, with the remainder using opioids as their principal prescription-only. drug. Most problem drug users in the Czech Republic inject their drug. The prevalence of problem drug use is Towards the end of the 1950s, a Czechoslovak factory highest in the capital city Prague. However, the estimated started to produce the amphetamines-based medicines 4 300 problem methamphetamine users make up only phenmetrazine (preludin) and dexphenmetrazine. Although about a third of problem drug users in the city, whereas in these drugs were intended for weight loss and the treatment the rest of the country they account for 80 % of problem of fatigue, depression and narcolepsy, their non-medical use drug users. is reported in the late 1950s. Consumption of the drugs increased greatly between 1959 and 1960, especially The most recent national estimate for Slovakia put the among students and professional drivers. By 1963–65, number of problem drug users in 2007 at 8 083 (5 783– phenmetrazine dependence accounted for around 40 % of 15 742), corresponding to 2.1 (1.5–4.0) cases per 1 000 drug users treated in inpatient psychiatric facilities. inhabitants aged 15–64. This represents a stable situation since 2005, which recent data suggests may have continued As a response to the increasing number of reported cases of in 2008. Subnational estimates by substance are not dependence in the 1970s, Czechoslovakia made the first available, but analysis of treatment demand indicator data steps to regulate phenmetrazine and dexphenmetrazine by suggests that outside the capital city, Bratislava, requiring a prescription for their purchase. During the same methamphetamine users make up a higher proportion of all period, manufacturing of methamphetamine in kitchen labs problem drug users entering treatment. and injecting of the drug emerged. Patterns of amphetamines use began to diverge between what is now Methamphetamine is reported as the primary drug by a the Czech Republic and Slovakia, though the two countries large number and proportion of clients entering treatment in were united until 1993. In what is now Slovakia, only a few the Czech Republic (4 700 clients, or 70 % of those entering small groups, mainly artists and university students, were treatment for amphetamines, cocaine or opioids) and known to use amphetamines, among several other drugs. In Slovakia (545 clients, 39 %) (Figure 4). Among those what is now the Czech Republic, small closed groups of entering treatment for the first time in their lives, the 23 users organised around methamphetamine producers, and proportions are higher ( ). Between 2003 and 2008, the by the late 1980s an estimated 25 000–30 000 users were number of first-time treatment entrants for problems relating dependent on non-alcohol drugs, principally pervitin. This to methamphetamine use increased in the Czech Republic 24 figure is comparable to the most recent estimates of problem and, especially, in Slovakia ( ). drug use in the Czech Republic. A large proportion of methamphetamine users in the Czech With the emergence of a pervitin black market in Republic enter treatment in low-threshold services or in 25 recreational settings, the period since 2000 has seen psychiatric outpatient and inpatient services ( ). pervitin use in the Czech Republic expand beyond small Considerable differences are reported between the different closed user groups. At the same time, recreational pervitin regions in the two countries. This may reflect differences not use spread in Slovakia, where problem methamphetamine only in the extent of the drug problem, but also in the use became extensive around 2004. availability of treatment and other factors. Methamphetamine users entering treatment in the Czech Problem amphetamines use today Republic and Slovakia are, on average, younger (25–26 years) than opioid clients (29 years). The male to female The number of problem methamphetamine users in the ratio of methamphetamines clients is close to unity in the Czech Republic in 2008 was estimated to be 21 200 Czech Republic (1.3:1), whereas in Slovakia male clients
(22) See Table PDU-102 in the 2010 statistical bulletin. (23) See Table TDI-5 (part i) and (part ii) in the 2010 statistical bulletin. (24) See Table TDI-3 in the 2010 statistical bulletin. (25) See also ‘Treatment options for problem amphetamines use’, below.
29 EMCDDA 2010 Selected issue
outnumber females by 3.4 to one. The number of women In order to investigate whether certain aspects of treatment entering treatment for primary methamphetamine use in the services are adapted to meet specific characteristics of Czech Republic is reported to be increasing, especially methamphetamine users, a series of surveys among nearly among the younger age groups (26). 30 psychiatric, counselling and drug treatment facilities were conducted. The surveyed health professionals Injecting is reported as the main route of drug administration considered that the therapeutic process related to by 80 % of methamphetamine clients in the Czech Republic methamphetamine dependence does not differ much from and by 36 % in Slovakia, though it is less frequently that of other substance-related dependencies. According to reported among those entering treatment for the first time in respondents from outpatient treatment centres, pervitin users their lives (27). Of methamphetamine outpatient clients in the tend to underestimate the severity of their drug problem, and Czech Republic, 43 % report using the drug occasionally, thus lack the motivation to change. First contacts are often 39 % 1–6 times a week, and 18 % daily (28), while in associated with a crisis and crisis interventions. Pervitin users Slovakia, 8 % report using it occasionally, 61 % 1–6 times a tend to drop out of treatment soon after admission or a few week, and 31 % daily (29). Use of other drugs, mainly contacts. Professionals also reported that most pervitin users heroin, cannabis and alcohol, is also often reported by are relatively young and often have family-related problems, primary users of methamphetamine. In addition, both so it is common to work within a family therapy context. countries report that the use of methamphetamine as a Older pervitin users are reported to have a more secondary substance is common, especially among heroin problematic polydrug use patterns and their conditions are users in substitution treatment. often complicated by psychotic symptomatology, which worsens the therapeutic prognosis. Methamphetamine users form the largest group of clients (53 %) of low-threshold facilities in the Czech Republic. Staff surveyed from detoxification centres reported similar Polydrug use is also common among these clients, with a experiences. According to them, pervitin users are often sizeable proportion (16 %) using pervitin in combination referred to the detoxification centres involuntarily (for with opioids. In Slovakia, a high proportion of drug users in example, through criminal justice referrals) in a state of contact with low-threshold programmes in 2008 reported acute toxic psychosis, which is typically accompanied by using methamphetamine, either as their sole drug (35.4 %) aggressiveness towards both themselves and their or in combination with heroin (14.7 %). environment. Patients often need to be restrained; communication with them is difficult, and they usually reject any care. Treatment options for problem amphetamines use In Slovakia, the relatively recent upsurge of In the Czech Republic, which has a long history of methamphetamine use negatively affected opioid users’ problem methamphetamine use, detoxification is the methadone maintenance treatment, as a considerable primary treatment for methamphetamine dependence. In proportion of clients were also methamphetamine dependent most cases, it is covered by universal health insurance. when they entered the treatment. Being dependent on two Detoxification is provided in inpatient treatment units drugs may counteract the effects of methadone on illicit associated with psychiatric departments within drug opioid use. Many stabilised or abstinent patients also started treatment or medical facilities that are either public or run using methamphetamine. As a consequence of these two by a non-governmental organisation. Unless severe elements, 12-month retention in methadone treatment physical withdrawal symptoms are observed, dropped from 77 % in 1999 to 46 % in 2003 — the period detoxification does not require specific pharmacological that corresponds to the upsurge of the methamphetamine treatment. Symptomatic therapy with antipsychotics is only epidemic in Slovakia. In response, the methadone recommended in indicated cases. Detoxified patients can maintenance programme in Bratislava developed a new be referred to either outpatient services or residential harm reduction modality, to complement the therapeutic rehabilitation, which include a wide range of psychosocial one. In the former, clients using methamphetamine were not interventions from cognitive behavioural therapies to excluded from treatment, but received a maximum daily therapeutic communities. dose of 40 mg of methadone and were not required to
(26) See Tables TDI-21 (part ii) and TDI-103 (part i) and (part iii) in the 2010 statistical bulletin. (27) See Table TDI-5 (part iii) and (part iv) in the 2010 statistical bulletin. (28) According to the TDI Protocol, occasional use means that the drug was not used in the month prior to entering treatment. (29) See Table TDI-111 (part v) and (part vi) in the 2010 statistical bulletin.
30 Problem amphetamine and methamphetamine use in Europe
become abstinent. The introduction of this new modality appears to have halted the drop in retention, which in 2008 improved to 54 %. About three to four times as many patients are enrolled in the therapeutic modality as in the harm reduction one, and only a few want to be transferred to the latter. On the other hand, patients of the harm reduction modality may be referred to the therapeutic modality based on their condition and motivation.
31 Conclusions
Focusing on countries where amphetamine or among young people in such settings varies considerably, methamphetamine is an important part of the drug problem, with levels of up to 30–70 % recorded in some studies in the this Selected issue has attempted to trace the historical Czech Republic, Hungary, Slovakia and the United development of amphetamines use since the introduction of Kingdom. Over the long term, there are signs that, at least in these substances as medicines in the 1930s. The history of some countries, amphetamines may have lost ground in the use of these substances is the result of an interplay of nightlife settings to cocaine or ecstasy, or new substances global forces, such as the rapid spread of recreational drug such as mephedrone. use in the 1960s and the arrival of heroin on the European drug scene in the 1970s, and local events such as the rise of In western and southern European countries, problem small-scale pervitin (methamphetamine) production in what amphetamines use is rare but can reach a certain level of was then Czechoslovakia. The outcome of this is that the importance in some countries and among specific present day amphetamines situation across Europe is populations of problem drug users. Contrastingly, in many marked by strong national characteristics, possibly more so northern, eastern and central European countries, than any other of the major illicit drugs. amphetamines users, often injecting, make up a sizeable proportion of the problem drug using population. In this Production of amphetamine in Europe appears to be situated wide geographical area, several distinct sub-patterns primarily in the Netherlands, Poland and Belgium, and to a emerge. The most obvious are the enduring amphetamine lesser extent in Estonia, Lithuania and Germany. By global problem in Sweden and Finland and the historical standards, illicit supply of methamphetamine in Europe is methamphetamine problem in the Czech Republic, which is from local small-scale ‘kitchen labs’ to limited international also affecting Slovakia. Other countries in these regions are trafficking, and is centred around two regions: central also affected, including Estonia, Lithuania, Latvia and Europe (especially the Czech Republic) and the Baltic Sea. Norway, where amphetamines are often injected, and It is important to note that while crystal methamphetamine Denmark where the drug is reported to be mainly snorted. and meth smoking are increasingly prevalent in many parts of the world, methamphetamine in Europe is available Withdrawal from amphetamines is not considered life- almost exclusively in powder form, and thus is virtually threatening, and successful detoxification is possible. Across indistinguishable from amphetamine in appearance and Europe, the treatment options available for amphetamines effect. Recent data from countries in the north of Europe users often reflect the national patterns and history of show that amphetamine could be increasingly replaced by problem amphetamines use. In western and southern methamphetamine on the markets of some Scandinavian European countries, treatment systems have specialised in and Baltic countries. responding mainly to the needs of opioid users, especially with opioid substitution treatment. In northern and central General population surveys and surveys among school European countries with a long history of treating students show a relatively low prevalence of amphetamines amphetamines use, some programmes are directed towards use in most European countries, but in at least five countries the needs of amphetamines users. In some other central and it is estimated that more than 2 % of young people (15–34) eastern European countries, significant problem have used the drug in the last year. Much of the less amphetamines use is more recent. Thus, treatment systems in problematic use of amphetamines takes place in recreational this area have primarily developed services for problem settings, particularly around dance music events, where use opioid users and appear to experience difficulties and of the drug appears to be more closely associated with shortcomings in addressing the needs of amphetamines certain music genres. Ever in lifetime use of amphetamines users.
32 References
ACMD (Advisory Council on the Misuse of Drugs) (2005), Degenhardt, L., Mathers, B., Guarinieri, M., Panda, S., Methylamphetamine review, technical report (available Phillips, B. et al. (2010), ‘Meth/amphetamine use and online). associated HIV: implications for global policy and public health’, International Journal of Drug Policy 21, pp. 347– Balakireva, O.M., Grund, J.P.C., Barendregt, C., Rubanets, 358. Y.V., Ryabova, M.V. et al. (2006), Risk and protective factors in the initiation of injecting drug use: analytical report on a EMCDDA (European Monitoring Centre for Drugs and Drug respondent driven sampling study & strategy paper Addiction) (2008), Drug use, impaired driving and traffic preventing the initiation of injecting drug use among accidents, EMCDDA Insights, Publications Office of the vulnerable adolescents and young people, Final Report, European Union, Luxembourg. UNICEF/UISR, Kiev. EMCDDA (2009), Preventing later substance use disorders in Bolding, G., Hart, G., Sherr, L. and Elford, J. (2006), ‘Use of at-risk children and adolescents: a review of the theory and crystal methamphetamine among gay men in London’, evidence base of indicated prevention, Thematic papers, Addiction 101, pp. 1622–1630. Publications Office of the European Union, Luxembourg (available online). Booth, R.E., Lehman, W.E., Kwiatkowski, C.F., Brewster, J.T., Sinitsyna, L. and Dvoryak. S. (2008), ‘Stimulant injectors in EMCDDA–Europol (2009), Methamphetamine: a European Ukraine: the next wave of the epidemic?’, AIDS and Union perspective in the global context, EMCDDA–Europol Behavior 12, pp. 652–661. joint publications, Lisbon and The Hague.
Borodkina, O.I., Baranova, M.V., Girchenko, P.V., Irwin, K.S., Goldberg, L. (1968), ‘Drug abuse in Sweden’, Bulletin on Heimer, R. and Kozlov, A.P. (2005), ‘The correlation Narcotics 1. between the type of drug use and HIV prevalence of IDU in different Russian cities’, Russian Journal of HIV/AIDS & Golub, M., Costa, L., Crofton, K., Frank, D., Fried, P. et al. Related Problems 9, pp. 74–75. (2005), ‘NTP-CERHR expert panel report on the reproductive and developmental toxicity of amphetamine and Chang, L., Alicata, D., Ernst, T. and Volkow, N. (2007), methamphetamine’, Birth Defects Research Part B: ‘Structural and metabolic brain changes in the striatum Developmental and Reproductive Toxicology 74, pp. associated with methamphetamine abuse’, Addiction 102, 471–584. pp. 16–32.
Grund, J.P., Coffin, P., Jauffret-Roustide, M. et al. (2010a), Chintalova-Dallas, R., Lutzenko, D., Lazzarini, Z. and Case, ‘The fast and furious: cocaine, amphetamines and harm P. (2009), ‘Boltushka: use of homemade amphetamine in reduction’, in European Monitoring Centre for Drugs and Odessa, Ukraine’, International Journal of Drug Policy 20, Drug Addiction (EMCDDA), Harm reduction: evidence, pp. 347–351. impacts and challenges, Rhodes, T. and Hedrich, D. CND (2009), World situation with regard to drug trafficking, (editors), Scientific Monograph Series No 10, Publications Commission on Narcotic Drugs, Economic and Social Office of the European Union, Luxembourg. Council, New York. Grund, J.P., Zábranský, T., Irwin, K.S. and Heimer, R. Darke, S., Kaye, S., McKetin, R. and Duflou, J. (2008), (2010b), ‘Stimulant use in central and eastern Europe: How ‘Major physical and psychological harms of recent social history shaped current drug consumption methamphetamine use’, Drug and Alcohol Review 27, pp. patterns’, in Pates, R. and Riley, D. (editors), Interventions for 253–262. amphetamine misuse, Blackwell, Oxford.
33 EMCDDA 2010 Selected issue
Gyarmathy, V.A., Neaigus, A., Mitchell, M.M. and Ujhelyi, E. Kaye, S., McKetin, R., Duflou, J. and Darke, S. (2007), (2009a), ‘The association of syringe type and syringe ‘Methamphetamine and cardiovascular pathology: a review cleaning with HCV infection among IDUs in Budapest, of the evidence’, Addiction 102, pp. 1204–1211. Hungary’, Drug and Alcohol Dependence 100, pp. 240–247. Mathers, B., Degenhardt, L., Phillips, B., Wiessing, L., Gyarmathy, V.A., Neaigus, A. and Ujhelyi, E. (2009b), Hickman, M. et al. (2008), ‘The global epidemiology of ‘Vulnerability to drug related infections and co-infections injecting drug use and HIV among people who inject drugs: among injecting drug users in Budapest, Hungary’, a review’, Lancet 372, pp. 1733–1745. European Journal of Public Health 19, pp. 260–265. McCambridge, J., Mitcheson, L., Winstock, A. and Hunt, N. Håkansson, A., Schlyter, F. and Berglunda, M. (2009), (2005), ‘Five-year trends in patterns of drug use among ‘Characteristics of primary amphetamine users in Sweden: a people who use stimulants in dance contexts in the United criminal justice population examined with the addiction Kingdom’, Addiction 100, pp. 1140–1149. severity index’, European Addiction Research 15, pp. 10–18. Melichar, J.K. and Nutt, D.J. (2010), ‘The mechanisms of amphetamine in the brain’, in Pates, R. and Riley, D. Hamamoto, D.T. and Rhodus N.L. (2009), (editors), Interventions for amphetamine misuse, Blackwell ‘Methamphetamine abuse and dentistry’, Oral Diseases 15, Publishing, Oxford. pp. 27–37. MHRA (Medicines and Healthcare Products Regulatory Hartnoll, R., Gyarmathy, A. and Zabransky, T. (2010), Agency) (2008), Information update: Implementation date ‘Variations in problem drug use patterns and their announced for tighter controls on nasal decongestants implications for harm reduction’, in European Monitoring (available online). Centre for Drugs and Drug Addiction (EMCDDA), Harm reduction: evidence, impacts and challenges, Rhodes, T. and NTA (National Treatment Agency for Substance Misuse) Hedrich, D. (editors), Scientific Monograph Series No 10, (2007), Drug misuse and dependence, UK guidelines on Publications Office of the European Union, Luxembourg. clinical management (available online).
Homer, B.D., Solomon, T.M., Moeller, R.W., Mascia, A., Nordahl, T.E., Salo, R. and Leamon, M. (2003), DeRaleau, L. and Halkitis, P.N. (2008), ‘Methamphetamine ‘Neuropsychological effects of chronic methamphetamine abuse and impairment of social functioning: a review of the use on neurotransmitters and cognition: a review’, Journal of underlying neurophysiological causes and behavioral Neuropsychiatry and Clinical Neurosciences 15, pp. implications’, Psychological Bulletin 134, pp. 301–310. 317–325.
Horwitz, R.I., Hines, H.H., Brass, L.M., Kernan, W.N. and Pates, R. and Riley, D. (2010), ‘The psychological and Viscoli, C.M. (2000), Phenylpropanolamine and risk of psychiatric effects of amphetamines’, in Pates, R. and Riley, hemorrhagic stroke: final report of the hemorrhagic stroke D. (editors), Interventions for amphetamine misuse, Blackwell project, Yale University School of Medicine (available Publishing, Oxford. online). Roll, J.M., Petry, N.M. and Stitzer, M.L. et al. (2006), HPA (Health Protection Agency) (2009), Hepatitis C in the ‘Contingency management for the treatment of UK, the Health Protection Agency annual report for 2008, methamphetamine use disorders’, American Journal of Health Protection Agency, London (available online). Psychiatry 163, pp. 1993–1999.
INCB (International Narcotics Control Board) (2010), Rosenberg, H., Melville, J. and McLean, P.C. (2002), Precursors and chemicals frequently used in the illicit ‘Acceptability and availability of pharmacological manufacture of narcotic drugs and psychotropic substances, interventions for substance misuse by British NHS treatment United Nations, New York (available online). services’, Addiction 97, pp. 59–65.
Jenner, L. and Saunders, J. (2004), ‘Psychostimulant Schepers, R.J., Oyler, J.M., Joseph, R.E., Cone, E.J., withdrawal and detoxification’, in Baker, A., Lee, N.K. and Moolchan, E.T. and Huestis, M.A. (2003), Jenner, L. (editors), Models of intervention and care for ‘Methamphetamine and amphetamine pharmacokinetics in psychostimulant users, National Drug Strategy Monograph oral fluid and plasma after controlled oral methamphetamine Series No 51, Australian Government Department of Health administration to human volunteers’, Clinical Chemistry 49, and Ageing, Canberra, pp. 35–50. pp. 121–132.
34 Problem amphetamine and methamphetamine use in Europe
Schifano, F., Corkery, J., Naidoo, V., Oyefeso, A. and Talu, A., Rajaleid, K., Abel-Ollo, K., Rüütel, K., Rahu, M. et Ghodse, H. (2010), ‘Overview of amphetamine-type al. (2010), ‘HIV infection and risk behaviour of primary stimulant mortality data UK, 1997–2007’, fentanyl and amphetamine injectors in Tallinn, Estonia: Neuropsychobiology 61, pp. 122–130. implications for intervention’, International Journal of Drug Policy 21, pp. 56–63. Scott, J.C., Woods, S.P., Matt, G.E., Meyer, R.A., Heaton, R.K. et al. (2007), ‘Neurocognitive effects of Tyner, E. and Fremouw, W.J. (2008), ‘The relation of methamphetamine: a critical review and meta-analysis’, methamphetamine use and violence: a critical review’, Neuropsychological Review 17, pp. 275–297. Aggression and Violent Behavior 13, pp. 285–297.
Sękiewicz, J. (2001), ‘Methamphetamine in Gdansk: a new UN (United Nations) (1976), Commentary on the convention pattern of drug use’, in UNDCP, Pompidou Group, Missing on psychotropic substances: done at Vienna on 21 February pieces, nine studies of emerging drug problems, United 1971, United Nations, New York. Nations, New York, pp. 101–131. UNODC (2010), World drug report 2010, United Nations Shaw, S.Y., Deering, K.N., Jolly, A.M. and Wylie, J.L. Office on Drugs and Crime, Vienna. (2010), ‘Increased risk for hepatitis C associated with solvent use among Canadian Aboriginal injection drug Van Haastrecht, H.J., van Ameijden, E.J., van den Hoek, users’, Harm Reduction Journal 7/16 (available online). J.A., Mientjes, G.H., Bax, J.S. and Coutinho, R.A. (1996), ‘Predictors of mortality in the Amsterdam cohort of human Shoptaw, S.J., Kao, U. and Ling, W. (2009a), ‘Treatment for immunodeficiency virus (HIV)-positive and HIV-negative amphetamine psychosis’, Cochrane Database of Systematic drug users’, American Journal of Epidemiology 143, pp. Reviews, Issue 1. 380–391.
Shoptaw, S.J., Kao, U., Heinzerling, K. and Ling, W. Vincent, N., Shoobridge, J., Ask, A., Allsop, S. and Ali, R. (2009b), ‘Treatment for amphetamine withdrawal’, Cochrane (1999), ‘Characteristics of amphetamine users seeking Database of Systematic Reviews, Issue 2. information, help and treatment in Adelaide, South Australia’, Drug and Alcohol Review 18, pp. 63–73. Singleton, J., Degenhardt, L., Hall, W. and Zabransky, T. (2009), ‘Mortality among amphetamine users: a systematic Wiessing, L., Guarita, B., Giraudon, I., Brummer- review of cohort studies’, Drug and Alcohol Dependence Korvenkontio, H., Salminen, M. and Cowan, S.A. (2008a), 105, pp. 1–8. ‘European monitoring of notifications of hepatitis C virus infection in the general population and among injecting Smith, L.M., LaGasse, L.L., Derauf, C., Grant, P., Shah, R. et drug users (IDUs): the need to improve quality and al. (2006), ‘The infant development, environment, and comparability’, Euro Surveillance 13(21):pii=18884 lifestyle study: effects of prenatal methamphetamine (available online). exposure, polydrug exposure, and poverty on intrauterine growth’, Pediatrics 118, pp. 1149–1156. Wiessing, L., van de Laar, M.J., Donoghoe, M.C., Guarita, B., Klempová, D. and Griffiths, P. (2008b), ‘HIV among Srisurapanont, M., Jarusuraisin, N. and Kittirattanapaiboon, injecting drug users in Europe: increasing trends in the East’, P. (2001), ‘Treatment for amphetamine dependence and Euro Surveillance 13(50):pii=19067 (available online). abuse’, Cochrane Database of Systematic Reviews, Issue 4. Wright, S., Klee, H. and Reid, P. (1999), ‘Attitudes of Strang, J. and Sheridan, J. (1997), ‘Prescribing amphetamine users towards treatment services’, Drugs: amphetamines to drug misusers: data from the 1995 Education, Prevention, and Policy 6, pp. 71–86. national survey of community pharmacies in England and Wales’, Addiction 92, pp. 833–838.
35 European Monitoring Centre for Drugs and Drug Addiction
Problem amphetamine and methamphetamine use in Europe
Luxembourg: Publications Office of the European Union
2010 — 35 pp. — 21 x 29.7 cm
ISBN 978-92-9168-450-2 doi: 10.2810/38745 How to obtain EU publications Our priced publications are available from EU Bookshop (http://bookshop.europa.eu/), where you can place an order with the sales agent of your choice.
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